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

We decided that the Plan has to pre-approve 13 fractions of 3D conformal radiation therapy for the enrollee.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says that only 10 daily treatments are allowed for the enrollee's treatment course.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 requested services. Our physician reviewer found that the enrollee has 2 oligometastases from renal cell carcinoma, one in the thoracic spine for which he underwent resection, to be followed by radiotherapy and another metastasis in the lung to be treated with SBRT. A mildly PET avid 8 mm retrocrual node is seen and considered non-specific. For oligometastases, it reasonable to offer higher doses of radiotherapy than what would be used for palliative radiation. The consult note discusses consideration for SBRT for minimally invasive surgery, and more comprehensive radiation for more extensive surgery, as was done. As the intent in this enrollee is not simply palliation of pain, and the radiation oncologist is concerned about the max dose to the cord if 10 fractions were to be delivered, treatment in 13 fractions is acceptable and would be considered furnished in accordance with accepted standards of medical practice. 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 requested services have been met. Therefore, we decided that the Plan has to pre-approve 13 fractions of 3D conformal radiation therapy for the enrollee.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services. You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee's condition is chronic and now stable.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. Continued services beyond March 11, 2020, were requested. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued services. Our physician reviewer found that active treatment was not taking place. It did not appear that the services were reasonably expected or medically necessary to improve your condition, or for the purpose of diagnosis. Based upon review the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond March 11, 2020. You could be treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations, delusions. You were not showing any behaviors or aggression being cooperative and compliant while not showing any acute threats to safety. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a capsule endoscopy.
You asked the Plan to pre-approve a capsule endoscopy. The Plan denied your request. The Plan says the physical exam is negative and there are no other gastrointestinal symptoms.
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 capsule endoscopy. Our physician reviewer found that you were recently hospitalized for left upper quadrant abdominal pain associated with splenic infarction. In evaluation of symptoms and iron deficiency anemia, small bowel follow-thru proved unremarkable. No abdominal tenderness was documented. The records do not support obscure GI bleeding, a source of which has not been diagnosed by EGD and colonoscopy. Your proposed indication of dysphagia/gastroesophageal reflux dues not support medical necessity for a capsule endoscopy. 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 capsule endoscopy have not been met. Therefore, we decided that the Plan does not have to pre-approve a capsule endoscopy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora diagnostic ultrasound provided on October 17, 2019 by an out of network (OON) provider.You asked the Plan to pay fora diagnostic ultrasound. You say that your doctor referred you to this facility. You say that you are on social security and cannot afford this.The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan says that no prior authorization was obtained.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 fora diagnostic ultrasound provided on October 17, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ferric carbomaltose injection provided on August 9, 2019.You asked the Plan to waive the coinsurance for the injection. The Plan denied your request. The Plan says that cost share is a contractual obligation under the plan and cannot be waived.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 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Medicare-covered Part B drug 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 ferric carbomaltose injection provided on August 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids
You asked the Plan to pre-approve the hearing aids. You say that regardless of the price you have been using the hearing aids made by this provider for the last 10 years and you prefer to keep using them as your equipment provider. The Plan denied your request. The Plan says hearing aids must be ordered directly from a certain provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when purchased from an in-network provider. The requested provider is not an in-network provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pre-approve hearing aids
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for PT provided on June 3, 2019.
You asked the Plan to waive the copayment for PT. You say that you disagree with the additional charges. 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 $40 copayment for outpatient rehabilitation services. You have been asked to pay a $40 copayment for PT. PT falls within the outpatient rehabilitation 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 copayment for PT provided on June 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the Part B injection provided on November 20, 2019.You asked the Plan to reduce the coinsurance for the Part B injection. You say that there is a huge price difference between this claim and your claim from December 3, 2019. You say you should be charged the less amount. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $1,191.60 which is 20% of the allowed amount for the Part B injection. The allowed amount is $5,958. ($5,958 x 20% = $1,191.60). The Part B 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 reduce the coinsurance for the Part B injection provided on November 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit, ophthalmic imaging and refraction provided on December 5, 2019.You asked the Plan to waive the cost share for the office visit, ophthalmic imaging and refraction. You say that you were informed the provider was in-network.The Plan denied your request. The Plan says the cost share applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductibleis $1,000. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Your contract with the Plan says that enrollees must pay 25% coinsurance for one out-of-network routine vision exam and up to two refractions annually.The office visit and ophthalmic imaging you asked the Plan to waive the cost share for fall within the "Physician/Practitioner services, including doctor's office visits" and "Outpatient diagnostic tests and therapeutic services and supplies" benefit categories. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 deductible applies to out-of-network office visits and diagnostic imaging. This cost sharing is a contractual obligation that had not been met at the time the office visit and ophthalmic imaging were received on December 5, 2019.Therefore, $204.44 was applied to the deductible. Since the refraction does not apply the deductible, you have also been asked to pay $4.95, which is 25% of the allowed amount for the refraction. The allowed amount is $19.79 (25% x $19.79 = $4.95). The refraction falls within the "Vision 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 cost share for the office visit, ophthalmic imaging and refraction provided on December 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on November 7, 2019.You asked the Plan to pay forthe ambulance services. You say that the Plan should allocate the charges as patient responsibility.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 7, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on November 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for endodontic therapy, molar tooth (excluding final restoration) (tooth #14 & 15) (D3330) provided on January 3, 2020.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says the service is not a covered benefit under the plan.
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. This service is not listed in your EOC as a covered benefit; therefore, it is not covered. Therefore, we decided that the Plan does not have to pay for endodontic therapy, molar tooth (excluding final restoration) (tooth #14 & 15) (D3330) provided on January 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to the enrollee from September 22, 2019 to September 29, 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 to the enrollee from September 22, 2019 to September 29, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genetic testing panel for spastic paraplegia.You asked the Plan to pre-approvethe genetic testing. The Plan denied your request. The Plan says the outcome of the testing will not change management of the spacity with baclofen and Botox.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 genetic testing. Our physician reviewer found that the documentation does not support the requested testing would impact your health, management and outcome. It has not been clearly demonstrated that the genetic testing would be clinically useful. Testing which has no proven relation to the management of a medical condition for the health of an enrollee is not a covered Medicare benefit. Therefore, the requested services are not considered medicallyreasonable or necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, we decided that the Plan does not have to pre-approvea genetic testing panel for spastic paraplegia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 18, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you were not aware that specialist visits were covered with a $10 copayment only 4 times per year. 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 $40 copayment per specialist office visit. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, doctor's office 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 copayment for a specialist visit provided on November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 16, 2019 through June 17, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital careis 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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found based on the documentation provided this hospitalization does not qualify for inpatient payment under the two-midnight rule. The enrollee was evaluated in the emergency department (ED) early on June 16, 2019. No obvious illness was identified, but the enrollee was presumptively started on treatment for aspiration. The treating physician(s) had most of June 16, 2019 and all of June 19, 2019 to further monitor the enrollee before deciding if two midnights of care would be required. As is, the enrollee was discharged on June 17, 2019 having spent only one midnight in the hospital.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 not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 16, 2019 through June 17, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit to be provided by an out of network (OON) provider at in network rates. You asked the Plan to pre-approve the outpatient office visit. You say that you are requesting a consultation and that it be covered as in network. You have seen about 12 physicians for your eye condition and there has not been any improvement. The Plan denied your request. The Plan says there are 48 in-network providers who can provide the requested service. The plan approved the enrollee to see an out of network provider but at the out of network rate. Medicare rules say that this PPO plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare. As a member of the PPO plan you can receive your care from either a network provider or an out-of-network provider. If you use an out-of-network provider, your share of costs for covered services may be higher. The requested provider in this case is not a network provider with the Plan. The plan contract specifically says if you use an out-of-network provider, your share of costs for covered services may be higher. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visit to be provided by an out of network (OON) provider at in network rates.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the catheter surgery (36902, 36215, 75710, and 99152) provided on December 16, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON catheter surgery. You say that you requested authorization for these services. The Plan denied your request. The Plan says these services were not authorized.
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 catheter surgery (36902, 36215, 75710, and 99152) provided on December 16, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat elevation system for a power wheel chairYou asked the Plan to pre-approve a power seat elevation system. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that [insert custom text from glossary]. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a power seat elevation system have not been met.Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system for a power wheelchair