Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mechanical traction therapy (97012 x 12) and ultrasound therapy (97035 x 12).
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says these services are not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pre-approve mechanical traction therapy (97012 x 12) and ultrasound therapy (97035 x 12).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from December 9, 2019 to December 13, 2019.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that you had no choice in which room you were given in the hospital. You say you have limited income. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (suchas copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment per day, days 1 to 5 at in-network inpatient hospitals. You have been asked to pay a $200 copayment for the inpatient hospital stay.($200 x 3 inpatient days = $600).  The inpatient hospital stay falls within the "Inpatient hospital 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 forthe inpatient hospital stay provided from December 9, 2019 to December 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection (J1050) you received on July 23, 2019.
You asked the Plan to pay for the injection. You say that the injection was given for pain. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that for the purposes of preventing conception, including services performed because a physician believes pregnancy would endanger the overall general health of the woman, are not considered to be reasonable and necessary for the diagnosis or treatment of illness or injury. We looked at the file and Medicare rules. The records do not show that the injection was given for pain or menstrual problems. The records show that the requested injection is being requested to prevent conception. Medicare rules state that services requested to prevent conception are not covered as they do not meet Medicare's definition of "reasonable and necessary". Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pay for the injection (J1050) you received on July 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an MRI and a Medicare Part B drug provided on December 19, 2019.
You asked the Plan to waive the coinsurance for an MRI and a Medicare Part B drug. You say that you thought that you would only owe a $300 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 20% coinsurance for diagnostic radiology and Medicare Part B prescription drugs. You received an MRI on December 19, 2019. The allowed amount is $1,590.40 and 20% of that is $318.08. You received a Medicare Part B drug on December 19, 2019. The allowed amount is $108.80 and 20% of that is $21.76. The total amount you owe is: $339.84. You have been asked to pay the total coinsurance amount of $339.84 for an MRI and a Medicare Part B drug. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. Medicare Part B prescription drugs fall 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 an MRI and a Medicare Part B drug provided on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on November 7, 2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you were informed you had no wax build-up and could leave. You say that the total charges are outrageous. 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 $25 copayment for urgently needed services at an in-network urgent care center.
You have been asked to pay a $25 copayment for the urgent care visit. The urgent care visit falls within the "Urgently needed services" benefit category. The records show that you were examined during the urgent care visit. 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 urgent care visit provided on November 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from December 25, 2019
to December 31, 2019.
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 are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be
covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The
Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.
We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare
and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does
not have to pay for the home infusion therapy rendered from December 25, 2019 to December 31, 2019.
Benefits for these services 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.
You asked the Plan to pre-approve the physician's services. You say that you had surgery performed by this physician on
September 18, 2019 and you would like to follow up with him. The Plan denied your request. The Plan says that generally you will only be referred to a doctor outside of your medical group if the specialists within your medical group cannot provide the care you need.
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 to pre-approve the requested physician's services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on November 18, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that the labs should have been covered. 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 $125 copayment for advanced imaging services provided at a freestanding radiological facility. You have been asked to pay the allowed amount of $119.08, which is less than the $125 copayment for a CT scan. A CT scan 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 a CT scan provided on November 18, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an MRI of the thoracic spine for the enrollee.
You asked the Plan to pre-approve the MRI. The Plan denied your request. The Plan says the enrollee has not completed comprehensive conservative pain therapy.
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 MRI. Our physician reviewer found that in the case of this enrollee, ongoing cervical, thoracic, and low back symptoms are causing chronic dysfunction. Recent thoracic examination findings did not clearly show objective signs of radiculopathy or other red flag diagnosis to justify an MRI right away. Also, although NSAIDs and opioids were being prescribed, other first and second-line medication options were not listed as having been tried to help manage the thoracic-related pain. Therefore, without sufficient support made for this request, the thoracic MRI will be considered not medically necessary 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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the thoracic spine for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that failure to undergo therapy will result in inadequate treatment. The Plan denied your request. The Plan says there are in-network providers who can provide the requested services.
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 OON services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested physician's services.You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 to pre-approve the requested physician's services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi electric hospital bed (E0260) and a commode chair (E0163).
You asked the Plan to pre-approve the semi electric hospital bed and a commode chair. You say that You were recently hospitalized due to chest pain and you have scoliosis and brittle bones. You have urinary incontinence and need to elevate your feet due to swelling in your legs. The Plan denied your request. The Plan says the commode chair and the semi-electric hospital bed is not medically necessary.
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. The file does not show that you are confined to a bed or room as defined by Medicare rules.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi electric hospital bed and a commode chair. Our reviewer says that this enrollee does not meet the Medicare criteria for the semi-electric hospital bed and the commode chair. Our physician reviewer found the enrollee's condition does not require positioning of the body in ways not feasible in an ordinary bed. The enrollee does not require frequent or immediate changes in body position. The enrollee does not require special attachments that cannot be fixed and used on an ordinary bed. The semi-electric hospital bed is not medically necessary for this enrollee. The records do not support that the patient is stuck in a single room or that the patient is stuck to one level of the home environment and there is no toilet on that level. The criteria for the commode has not been met. 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 semi electric hospital bed and a commode chair have not been met. Therefore, we decided that the Plan does not have to pre-approve the semi electric hospital bed (E0260) and a commode chair (E0163).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from September 5, 2019 to
September 16, 2019.
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 claims were not billed correctly.
The Plan must follow Medicare rules. The rules say that the Type of Bill (TOB) code 032x is required for home
health services under a plan of treatment.
We looked at the file and Medicare rules. The file shows that the claims were not billed with a valid TOB code.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pay for the home health services rendered from September
5, 2019 to September 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transportation provided on December 13,
2019, and December 17, 2019.
You asked the Plan to pay for the transportation. The Plan denied your request. The Plan says ambulance
transport to a doctor's office is not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when
they meet certain origin and destination requirements. A doctor's office is not a covered destination.
The services you have asked the Plan to pay for are ambulance transport services to a doctor's office.
Therefore, we decided that the Plan does not have to pay for the ambulance transportation provided on
December 13, 2019, and December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the requested varicose vein treatment.
You asked the Plan to pre-approve the varicose vein treatment. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 to pre-approve the requested varicose vein treatment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the OON services. You say that the services are medically necessary. The Plan denied your request. The Plan says there are providers in-network able to provide the care the enrollee needs.
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 file shows an arthroscopic knee surgery was requested for the enrollee. 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 OON services. Therefore, we decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 hours of home health aide services (G0156) for 9 weeks and 9 skilled nursing visits (G0299).
You asked the Plan to pre-approve home health services. You say that the enrollee previously received these services. The Plan denied your request. The Plan says the enrollee does not have skilled needs.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 home heath services. Our reviewer says
that the requested services are not medically necessary beyond what was approved by the health plan. Our physician reviewer found the records do not show that the remaining skilled nursing services are required to effectively provide treatment, care, or services which are medically necessary for the patient beyond what was approved by the health plan. There are no complex wounds, IV medications, new enteral feedings or other skilled nursing need that require these services. The requested 12 hours of home health aide services (G0156) for 9 weeks exceed the skilled needs of a nurse and are not necessary to the treatment of the patient's illness or injury by the skilled professional staff. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 hours of home health aide services (G0156) for 9 weeks and 9 skilled nursing visits (G0299).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea maxillary partial denture (D5213).You asked the Plan to pre-approvethe maxillary partial denture. You say that this enrollee has lost their partial, which is essentialfor them to retain teeth and chew with.The Plan denied your request. The Plan says this service exceeds the maximum count allowed per period.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, partial dentures are limited to one procedure every five plan years. The record shows that the enrollee received a partial denture on October 31, 2017 and the enrollee's partial denture benefit has been exhausted.Therefore, we decided that the Plan does not have to pre-approvea maxillary partial denture (D5213).