Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatientrehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the enrollee had a major spine issue so you feel that the enrollee needs a rehab not skilled nursing. You are familiar with this facilityand it is a very good facility.The Plan denied your request. The Plan says inpatient rehabilitation is not medically necessary. A lower level of intensity such as skilled nursing would be more appropriate.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the documentation does not reveal that the enrollee'smedical status requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.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 topre-approveacute inpatient rehabilitation facility (IRF) admission and services.
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 you cannot be cared for at home.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. While you may benefit and participate inadditional physical and occupational therapy, you not require this on an intensive rehabilitation facility therapy program level in an IRF.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea consultation to be providedby an out-of-network (OON) urologist.You asked the Plan to pre-approvethe consultation. You say that you are not happy with plan's doctor.The Plan denied your request. The Plan says the services are available in-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 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-approvea consultation to be provided by an out-of-network (OON) urologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forpanoramic x-rays (D0330) provided November 20, 2019.You asked the Plan to pay forthe x-rays. You say that if you had been told that this service was not covered and you would have to pay for it then you would not have had it done.The Plan denied your request. The Plan says this service is 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 forpanoramic x-rays (D0330) provided November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional $40 to your over-the-counter benefits.You asked the Plan to pre-approvethe additional over-the-counter benefits. You say that your PCP is requesting you take the over-the-counter drugs and you are unable to get these items without the benefit.The Plan denied your request. The Plan says your request exceeds the over-the-counter benefit amount allowed as stated in the EOC.The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the additional over-the-counter benefits is an OTC item. The Plan offers supplemental over-the-counter benefits;therefore,the Plan rules apply in this case. We looked at your request, the file and the rules. Based on this information, we find that the Plan rules for coverage of the additional over-the-counter benefits have not been met. Specifically, your request exceeds the over-the-counter benefit amount allowed.Therefore, we decided that the Plan does not have to pre-approvean additional $40 to your over-the-counter benefits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe fecal blood test provided on November 22, 2019.You asked the Plan to waive the copayment forthe fecal blood test. You say that this was included with your annual physical. You say that this should fall under the colorectal screening.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 $20 for Medicare-covered laboratory tests. You have been asked to pay $17.67, which is less than the $20 copayment for the fecal blood test. The fecal blood test falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The fecal blood test is considered a separate outpatient diagnostic test. 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 fecal blood test provided on November 22, 2019.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to reduce the copay for the lab services. We decided that the Plan does not have to completely waive the copay for the lab services.
You asked the Plan to waive the copay for the lab services. You say that you should not be responsible for the labs because they were during your annual visit. The Plan says that the copay was applied based on your plan benefits.
We decided that the Plan has to reduce the copay for the lab 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).
The file shows you received lab services on October 17, 2019. The claim information provided shows the allowed amount for the labs totaled $11.55. Because the amount is less than your $20 copay, you should have been charged the lesser amount. You cannot be asked to pay more than the allowed amount. Therefore, we decided that the Plan has to reduce the copay for the lab services you received on October 17, 2019.
We also decided that the Plan does not have to completely waive the copay for the lab 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).
The services fall under the outpatient diagnostic tests benefit category. This means that you have been asked to pay a copay 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 completely waive the copay for the lab services you received on October 17, 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.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging.
You asked the Plan to pre-approve the imaging. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that cardiovascular nuclear imaging is covered for the above indications.
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 imaging. Our reviewer says that myocardial perfusion imaging is not medically reasonable and necessary. Our physician reviewer found that chest pain for 20 or more days was reported, worked-up in the ER, and as outpatient, an exercise stress test revealed no angina or need for any further testing. There was no evidence for any of the required indications for myocardial perfusion imaging to justify this request. Therefore, this request for myocardial perfusion imaging will be considered not medically 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 imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging.
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 this is medically necessary. The Plan denied your request. The Plan says you can be treated at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. While you may benefit and participate in additional physical and occupational therapy, you do not require this on an intensive rehabilitation facility therapy program level in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit provided on June 7, 2018.
You asked the Plan to waive the copayment for the office visit. You say that this is your primary care doctor. You say that your copayment is $20 per visit. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms how much you should expect to pay for an office visit with a primary care physician you have not chosen. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $30 specialist copayment for an office visit with a primary care physician you have not chosen. The Plan contract does not clearly say how much enrollees must pay for the office visit with a primary care physician you did not choose. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the office visit provided on June 7, 2018.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for periodic oral exam (D0120) intraoral periapical first x-ray (D0220) intraoral- periapical each additional x-ray (D0230) and bitewing x-rays (D0274) provided November 1, 2019.
You asked the Plan to pay for the dental service. You say that had you been made aware how much was left on your account or that there was a limit of $1000 per year of coverage you would not have had the services. The Plan denied your request. The Plan says this request exceeds the annual maximum benefit limit.
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 has an annual maximum of $1,000 for dental benefits. You are responsible for paying all services once the annual maximum is exhausted. 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 periodic oral exam (D0120) intraoral periapical first x-ray (D0220) intraoral- periapical each additional x-ray (D0230) and bitewing x-rays (D0274) provided November 1, 2019.
Appeal type: Supplemental Benefit
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 oral evaluation. You say that you need a root canal that your clinic cannot provide for you. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and this dental service is not covered by Medicare or 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 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 the medical services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the standard wheelchair rental provided on July 13, 2019 by an out of network provider.
You asked the Plan to pay for the standard wheelchair rental. You say that the Plan should pay for the medically necessary services. The Plan denied your request. The Plan says prior authorization was not requested.
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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for this item. Therefore, we decided that the Plan does not have to pay for the standard wheelchair rental provided on July 13, 2019 by an out of network provider
.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a LINX Reflux Management System (43284).
You asked the Plan to pre-approve the LINX Reflux Management System. You say that the LINX Reflux Management System is FDA approved and the scientific evidence permits conclusions concerning the effect of the technology on health outcomes. The Plan denied your request. The Plan says the LINX Reflux Management System is unproven and therefore denied under Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LINX Reflux Management System have not been met. Specifically, per Medicare's Local Coverage Article: Billing and Coding: Upper Gastrointestinal Endoscopy and Visualization (A56389), CPT code 43284 is a non-covered code. Therefore, we decided that the Plan does not have to pre-approve a LINX Reflux Management System (43284).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the gingival irrigation (D4921) for all 4 quadrants provided on September 4, 2019.
You asked the Plan to pay for the dental services. You say that the services were provided by an in network provider. You say that the services should be covered under the 6-month preventive dental exam. You also say that the services are to prevent gingivitis. The Plan denied your request. The Plan says gingival irrigation is not listed as a covered service.
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, gingival irrigation is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921) for all 4 quadrants provided on September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the DME provided on August 21, 2019.
You asked the Plan to reduce the coinsurance for the DME. You say that you were charged incorrectly. 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% of the cost for Medicare-covered durable medical equipment. You have been asked to pay a total of $1,281.08 for the DME. The DME falls within the "Durable medical equipment (DME) and related 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 reduce the coinsurance for the DME provided on August 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve feboxustat 40mg tablets.
You asked the Plan to pre-approve the feboxustat tablets. You say that the enrollee needs this medication. The Plan denied your request. The Plan says this oral drug is not covered by Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve feboxustat 40mg tablets.
Benefits for the feboxustat tablets 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve One Touch Ultra Blue diabetic testing strips.
You asked the Plan to pre-approve One Touch Ultra Blue test strips. You say that you have always used this brand and need these tests strips. The Plan denied your request. The Plan says the denial of authorization for these supplies is correct, because the Plan's preferred diabetic testing supplies can meet your needs. The Plan also says that, to help transition, the Plan will approve a request for 3 months of the requested testing supplies with no refills beyond this.
The Plan must follow Medicare rules. Medicare rules say that Plans may specify brands and manufacturers as preferred brands and may limit supply to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items. We looked at the file and Medicare rules. The Plan's preferred diabetic testing supply brands can meet your needs. Based on this information, we decided that Medicare rules for coverage of One Touch Ultra Blue test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve One Touch Ultra Blue diabetic testing strips.