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

We decided that the Plan does not have to pre-approve a referral for a second opinion with an out-of-network dental provider.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says network providers must be used.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral for a second opinion with an out-of-network dental provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF)careprovided from July 5, 2020, through July 14, 2020.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the enrollee has exhausted the 100 day skilled nursing benefit.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone sixtydays in a row without inpatient hospital or SNF care.The file shows that the enrolleereceived 100 days of SNF care during the benefit period from January 23, 2020, through July 4, 2020. The Plan has covered 100 days of SNF care.Although the enrollee may still need skilled care, the Plan is not requiredto pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when he has not been receiving care in a hospital or skilled care in a SNF for at least sixtydays in a row.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF)careprovided from July 5, 2020, through July 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF 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 IRFcare. Our reviewer says that the enrollee does not meet criteria for IRF admission. Our physician reviewer found based on the documentation provided, the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee isnot shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered from June 17, 2019 to October 15, 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 claim was billed incorrectly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an outpatient rehabilitation setting and should have been billed with POS code 32.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered from June 17, 2019 to October 15, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services provided to the enrollee on May 29, 2020.
You asked the Plan to pay for the services. You say that at the time of service the enrollee was not in hospice. The Plan denied your request. The Plan says the services should be billed to Original Medicare.
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 May 22, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for hospital services provided to the enrollee on May 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Meningococcal conjugate vaccine and administration charge
provided on September 16, 2020.
You asked the Plan to pay for Meningococcal conjugate vaccine and administration charge. You say that the
Plan should pay this claim. The Plan denied your request. The Plan says this immunization is not covered under
your Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide Meningococcal
conjugate vaccine and administration charge. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to Meningococcal
conjugate vaccine and administration charge. Therefore, we decided that the Plan does not have to pay for
Meningococcal conjugate vaccine and administration charge provided on September 16, 2020.
Benefits for Meningococcal conjugate vaccine and administration charge 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex device.You asked the Plan to pre-approvea Vertiflex device. You say that the requested Vertiflex device is medically necessary.The Plandenied your request. The Plan says the requested Vertiflex device is not medically necessary.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 a Vertiflex device. Our reviewer says that the requested Vertiflex device is not medically necessary. Our physician reviewer found the enrollee is with back pain. The requested Vertiflex device is experimental. More research is needed to show safety and efficacy. It is not medically necessary 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 a Vertiflex device have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex device.
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 the documentation
provided, 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.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services (D2740, D2950) provided on June 24, 2020.You asked the Plan to pay forthe dental services. You say that the services were medically necessary.The Plan denied your request. The Plan says out-of-network dental services are not covered.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 services at issue in this appeal. The Plan did not pre-approve the service 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 forthe dental services (D2740, D2950) provided on June 24, 2020.
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. The Plan denied your request. The Plan says review of medical records available does not support medical necessity for care with 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 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 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 topre-approve physician's services to be provided by the out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran electrocardiogram (99214) provided July 22, 2020.You asked the Plan to waive the copayment forthe electrocardiogram. You say that the copayment should be waived.The Plandenied your request. The Plan says the correct copayment was 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 $10 copayment for diagnostic tests. You have been asked to pay a $10 copayment for the electrocardiogram. The electrocardiogram falls within the diagnostic tests benefit category. This means that you have been asked topay 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 foran electrocardiogram (99214) provided July 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not have to pay forthe dental services rendered on March 31, 2020.You asked the Plan to pay forthese services. You say that the provider is your personal dentist.The Plan denied your request. The Plan says the provider is excluded fromparticipating in Medicare.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. The file shows that you received services from a dental provider that is not a Medicare provider.Therefore, we decided that the Plan doesnot have to pay forthe dental services rendered on March 31, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Medicare Part B drugs and physician visits provided January 14, 2020, to February 24, 2020, by an out-of-network (OON) provider.
You asked the Plan to waive the cost share for the Medicare Part B drugs and physician visits. You say that you would like this cost share waived. The Plan denied your request. The Plan says the cost share has applied correctly in this case.
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 30% coinsurance for OON Medicare Part B drugs and physician visits. You have been asked to pay a 30% coinsurance for the Medicare Part B drugs and physician visits. The services provide fall within the OON Medicare Part B drugs and physician visits 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 cost share for the Medicare Part B drugs and physician visits provided January 14, 2020, to February 24, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe outpatient surgery services provided from July 13, 2020 to September 25, 2020.You asked the Plan to waive the copayments forthe outpatient surgery services. You say that you feel you should not be responsible 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 outpatient surgery services on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.The rules say a plan must disclose to its enrollees in clear, accurateterms 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 Outpatient hospital services. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient surgical services provided from July 13, 2020 to September 25, 2020. You have been asked to pay a $225 copayment for each outpatient surgery service, totaling $1800. The outpatient surgery services fall within the Outpatient hospital 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 copayments forthe outpatient surgery services provided from July 13, 2020 to September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on April 30, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says the Plan
requires utilization of network providers when possible and available, and requires authorization for certain
services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has
been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
psychotherapy services. We found no exception that would require the Plan to pay for these services.
Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on April 30,
2020.
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 requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not
medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the
enrollee is receiving acute care hospital services and these services have not been denied. He is not
hemodynamically stable during weaning efforts and does not have long-term access for ventilator and
nutritional support. The LTACH would not provide services that the enrollee is not already receiving.
Therefore, the medical necessity of transfer to LTACH is not established.
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.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenipple/areola reconstruction (19350) and brachioplasty (arm lift) (15836).You asked the Plan to pre-approvenipple/areola reconstruction (19350) and brachioplasty (arm lift) (15836). You say that the requested plastic surgery is considered cosmetic and is medically necessary.The Plan denied your request. The Plan says the requested plastic surgery is considered cosmetic and is not medically necessary.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 nipple/areola reconstruction (19350) and brachioplasty (arm lift) (15836). Our reviewer says that the requested plastic surgery is considered cosmetic and is not medically necessary. Our physician reviewer found the enrollee is with a history of morbid obesity, who previously underwent gastric bypass surgery and subsequent panniculectomy. More recently the enrollee underwent bilateral reduction mammoplasty. It is noted that the left nipple points more inferiorly than the right nipple to a small extent. Nipple/areola reconstruction may alter the enrollee's appearance to a small extent, but would not improve function. Consequently, the requested nipple/areola reconstruction is considered cosmetic in nature, and not medically reasonable and necessary. The enrollee's plastic surgeon writes, "As part of a continued stage reconstruction, we are planning on moving on to her arms next. She has significant back and neck pain, which could conceivably be relieved by removal of this excess tissue. Shealso has a fair amount of posteromedial skin and subcutaneous excess, which makes it difficult to fit into her clothes and also impairs her mobility." Evidence that brachioplasy impacts back and neck pain and activities of daily living is lacking. The requested brachioplasty is not considered medically reasonable and necessary 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 nipple/areola reconstruction (19350) and brachioplasty (arm lift) (15836) have not been met.Therefore, we decided that the Plan does not have to pre-approvenipple/areola reconstruction (19350) and brachioplasty (arm lift) (15836).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forradiologic examination, hip, unilateral (73501) provided September 2, 2020.You asked the Plan to waive the copaymentforthe x-ray. You say that you are appealing because you thought this would have been covered under your follow up because the only way to follow up is to take an x-ray.The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.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 $40 for each basic imaging service (general x-rays or ultrasound). You have been asked to pay $40 for the x-ray. The plan has confirmed that the x-ray provided is not included in the global surgical package. The x-ray falls within the Outpatient diagnostic test 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 Plandoes not have to waive the copayment forradiologic examination, hip, unilateral (73501) provided September 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 6, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe wound care. Yousay that you would like reconsideration because services were rendered prior to authorization being obtained to void delay in care which could result in wound complications.The Plan denied your request. The Plan says the member is required to use doctors who are a part of her network.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 medical services provided on July 6, 2020 by an out of network (OON) provider.