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

We decided that the Plan does not have to pay more for the emergency care you received outside the United States from October 11, 2019, to October 13, 2019. You asked the Plan to pay more for the services. You say that you want to be reimbursed for the services.The Plan denied your request. The Plan says you did not submit receipts for the services. 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 $120 copayment for worldwide emergency room visits. Review of the file shows that you were provided emergency care out of the country from October 11, 2019, to October 13, 2019. You have been asked to pay a $120 copayment for the services. The services fall within the emergency care 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. Additionally, the records do not show documentation of the $163.40 charge you incurred during your travels. It is your responsibility to supply the plan with sufficient information to determine whether payment is due. Without receipts, it cannot be determined whether payment should be made for these services. Therefore, we decided that the Plan does not have to pay more for the emergency care you received outside the United States from October 11, 2019, to October 13, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Rezum procedure for the enrollee. You asked the Plan to pre-approve the procedure. You say that this is medically necessary.The Plan denied your request. The Plan says the water vapor procedure is considered investigational. 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 the procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the most recent AUA Guidelines, the support for use of the Rezum procedure in men with BPH is quite weak. Further trials comparing Rezum (water-induced thermotherapy), are needed to determine their long-term efficacy and superiority compared to standard treatments for BPH/LUTS.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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Rezum procedure for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant, osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia provided on June 8, 2017. You asked the Plan to pay for the endosteal implant, osseous, osteoperiosteal, or cartilage graft, and intravenous moderate (conscious) sedation/analgesia. You say that this implant was scheduled and recommended by two providers. The Plan denied your request. The Plan says implant services are not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant, osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla, and each subsequent 15 minute increment of intravenous moderate (conscious) sedation/analgesia provided on June 8, 2017.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Bioness L300 Go lower system for the enrollee. You asked the Plan to pre-approve the system. You say that this is medically necessary. The Plan denied your request. The Plan says the records received do not show any of the covered indications. The Plan must follow Medicare rules. Medicare rules say that a spinal cord stimulator is only covered for use in spinal cord injury patients. 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 system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is noted to have foot drop secondary to their primary neurological condition - multiple sclerosis. According to the applicable NCD (Neuromuscular Electrical Stimulation (NMES) (160.12) - Effective October 1, 2006), the requested technology is currently only covered by Medicare for use in spinal cord injury patients with specific characteristics. There is no history of spinal cord injury. 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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Bioness L300 Go lower system for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on December 6, 2019. You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening services are not covered. The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on December 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyewear provided to the enrollee on May 16, 2019. You asked the Plan to pay for the eyewear. You say that this should be covered because the enrollee had cataract surgery. The Plan denied your request. The Plan says that you cannot request payment after the second surgery. Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan states that if you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.We looked at the file and the Plan's rules. The file indicates that reimbursement for the eyewear was requested after the enrollee's second cataract surgery. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the eyewear provided to the enrollee on May 16, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on November 20, 2018. You asked the Plan to pay for the anesthesia services. You say that the enrollee revoked their hospice on November 20, 2018. The Plan denied your request. The Plan says during the election, fee-for-service Medicare also 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. 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 for the anesthesia services provided on November 20, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidural injection.You asked the Plan to pre-approve an epidural injection. You say that the requested epidural injection is medically necessary.The Plan denied your request. The Plan says the requested epidural injection does not meet criteria. 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 an epidural injection. Our reviewer says that the requested epidural injection does not meet criteria. Our physician reviewer found the enrollee is with pain and radiculopathy lumbosacral region. She received an epidural steroid injection on 2/17/20 and reported minimal relief. She is presently using Aleve for pain relief. A second epidural steroid injection has been requested. Epidural steroid injections (ESIs) are recommended as an option for treatment of radicular pain (defined as pain in a dermatomal distribution with corroborative findings of radiculopathy). Most current guidelines recommend no more than 2 ESI injections. Research has shown that, on average, less than two injections are required for a successful ESI outcome. ESIs can offer short-term pain relief and use should be in conjunction with other rehab efforts. The purpose of ESIs is to reduce pain and inflammation, restoring range of motion and thereby facilitating progress in more active treatment programs, and avoiding surgery, but this treatment alone offers no significant long-term functional benefit. The American Academy of Neurology recently concluded that epidural steroid injections may lead to an improvement in radicular lumbosacral pain between 2 and 6 weeks following the injection, but they do not affect impairment of function or the need for surgery and do not provide long-term pain relief beyond 3 months. Per the coverage criteria, injections are performed independently based on the patient's symptoms and response to prior injections and approach (if performed). There is no role for a routine "series of 3" or undocumented response "test dosing." Repeat or serial test or diagnostic injections without documented response are not considered reasonable and necessary. Response to each epidural injection should be determined prior to determining the value of a repeat injection and the specific methods used for subsequent epidurals. The review has determined that the enrollee does not have a covered indication for the requested epidural injection as the first injection provided little to no relief. 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 epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural injection.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for diagnostic testing provided on April 8, 2019 by an out-of-network provider. You asked the Plan to pay for the services. You say that this should be reprocessed because you have a referral from the enrollee's primary care provider. The Plan denied your request. The Plan says there is no valid referral for this service. 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 Plan contacted the enrollee's primary care physician and confirmed that they did not refer the member over for these services. 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 diagnostic testing provided on April 8, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 17, 2018 by an out of network (OON) provider. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 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 medical services provided on July 17, 2018 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 6, 2019 by an out of network (OON) provider. You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without 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 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 medical services provided on November 6, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve crown - porcelain fused to high noble metal (D2750) on tooth 11. You asked the Plan to pre-approve the dental services. You say that please reprocess the predetermination. Additional information requested has been submitted. The Plan denied your request. The Plan says that crown on tooth 11 is not reasonable or necessary and does not meet the coverage criteria. 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 dental services 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 dental services. Our reviewer says that the criteria has been met. Our physician reviewer found the large restoration and incisal defect on tooth #11 indicates significant coronal breakdown. Due to the degree of breakdown, the criteria for coverage for a crown (D2750) for tooth #11 have been met. 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 dental services have been met. Therefore, we decided that the Plan has to pre-approve crown - porcelain fused to high noble metal (D2750) on tooth 11. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on October 16, 2019. You asked the Plan to waive the copayment for an EGD. You say that you required a latex free facility and feel that you should only owe a $50 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received an EGD on October 16, 2019. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $150 copayment. You have been asked to pay a $150 copayment for an EGD. An EGD falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for an EGD provided on October 16, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from August 18, 2019 to August 29, 2019. You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly. The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim is missing the required FIPS code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from August 18, 2019 to August 29, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Emergency Room services provided on December 3, 2019. You asked the Plan to waive the copayment for the Emergency Room services. You say that the copayment should be $90 and not $180 dollars. The Plan denied your request. The Plan says the copayment being applied is only $90. 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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the Emergency Room services. The Emergency Room services falls within the Emergency Care 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 Emergency Room services provided on December 3, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from November 3, 2019 to November 11, 2019. You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient admission was medically necessary. The Plan denied your request. The Plan says that the enrollee does not meet inpatient criteria. The enrollee meets observation level of care. The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found enrollee had a history of COPD on home oxygen who presented to the emergency department on November 3, 2019 with increased SOB. Initially, she required BIPAP. She was evaluated and her CXR demonstrated interstitial lung disease changes with a question of pulmonary edema. She was treated with IV antibiotics, IV Steroids and IV Lasix. She was admitted and had an echocardiogram which revealed an EF of 35 %. She was evaluated by cardiology but refused a full evaluation. She was also evaluated by palliative care/hospice. Her condition stabilized and she was discharged to SNF/Hospice. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from November 3, 2019 to November 11, 2019. 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.