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

We decided that the Plan does not have to pay for acute inpatient hospital care provided July 26, 2019 through July 27, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you are appealing the denial for an inpatient stay. The Plan denied your request. The Plan says it could not be concluded that severe symptoms or findings not responsive to emergency or observation care treatment were present. The patient's symptoms resolved quickly. After one night the patient was discharged back to his assisted living center. Criteria for inpatient admission was not met.
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 does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found this hospitalization does not qualify for inpatient payment under the two-midnight rule. The enrollee presented to the emergency department (ED) early on July 26, 2019. The enrollee's vital signs were stable. The ED provider believed that the enrollee was appropriate for observation status. Given the time frame, the hospitalized service had most of July 26, 2019 and all of July 27, 2019 to further monitor the enrollee before deciding on two midnights of care (July 26, 2019 through July 28, 2019). The enrollee remained stable overnight and was discharged having received one midnight of care (July 26, 2019 through July 27, 2019).
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 acute inpatient hospital care provided July 26, 2019 through July 27, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from June 21, 2019 through June 27, 2019.You asked the Plan to waive the copayment for the inpatient stay. You say that there was no reason to be kept for five days. You say that you should not be charged for the stay.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 $300 copayment per day for days 1-5 and a $0 copayment per day for additional days for in-network, Medicare-covered inpatient hospital stays.You have been asked to pay a $1,500 copayment for the inpatient stay. ($300/day x 5 days = $1,500). The inpatient 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 for the inpatient stay provided from June 21, 2019 through June 27, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided on April 14, 2019.You asked the Plan to pay forthe ambulance service. You say that the Plan should pay the claim.The Plan denied your request. The Plan says the enrollee's auto insurance payment exceeded the Plans allowable amount and therefore additional payment is denied.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment.Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the bill was paid, over the Plan's allowable amount, by the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the ambulance service unlessthe primary insurer has denied the claim for these servicesor underpaid.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided on April 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on September 6, 2019.You asked the Plan to pay forthe services. You say that this was medically necessary testing.The Plan denied your request. The Plan says a site investigation was completed and it was found that the address listed on these claims does not house a laboratory owned by the billing company, nor has there ever been a laboratory there. As such, this claim is not payable due to the fraudulent address reported.The Plan must follow Medicare rules. Medicare rules say that that allinformation must corroborate the documentation in the record and support that coverage criteria are met. In this case, the Plan attests that the address listed on this claim is not valid as there is no laboratory operating at that address. As such, we find that this claim does not corroborate other information in the record and is correctly denied.Therefore, we decided that the Plan does not have to pay forthe services provided to the enrollee on September 6, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on July 24, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the member has no out-of-network benefits. The Plan says that no prior authorization was obtained for these 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 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 foran office visit provided on July 24, 2019 by an outof network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for enrollee.You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs respiratory management, antibiotics, cardiac support, and daily physician monitoring.The Plan denied your request. The Plan says the enrollee is already receiving necessary acute services in an acute hospital setting.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a heart attack. The enrollee underwent coronary intervention. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.You asked the Plan to pre-approve Entyvio. You say that the enrollee has tried and failed multiple conventional therapies, including Prednisone.The Plan denied your request. The Plan says the enrollee has not had prior therapy, a contraindication to, or intolerance with Remicade or Inflectra; and Stelara.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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 Entyvio. Our physician reviewer found that the enrollee has a diagnosis of ulcerative colitis. The Plan requires a trial of drug Remicade or Inflectra; and Stelara before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs. The documentation does not support that Remicade or Inflectra, and Stelara would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Epinephrine Inj 0.3mg.You asked the Plan to pre-approve Epinephrine Inj 0.3mg. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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 Epinephrine Inj 0.3mg.Benefits for Epinephrine Inj 0.3mgmay 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 the Perfect Walker II walker.You asked the Plan to pre-approvethe upright mobility walker.You say that you need the Perfect Walker II so you can walk with your back straight not bent down.The Plan denied your request. The Plan says neither Medicare nor the Plan cover upright mobility walkers.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have standard walker. The standard walker serves the same purpose as the upright mobility walker.Medicare only covers standardwalkers. Therefore, we decided that the Plan does not have to pre-approvethe Perfect Walker II walker.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe office visit and x-rays provided on July 31, 2019.You asked the Plan to waive the deductible forthe office visit and x-rays. You say that you were informed the specialist was in-network. You say that the bill amount is more than expected.The Plan denied your request. The Plan says the deductible 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 deductible is $500, which applies to all items and services except those specifically excluded by the Plan's contract. This is the amount you have to pay out-of-pocket before we will pay our share foryour covered medical services. Out-of-network services are not excluded from the deductible. The item or service you asked the Plan to waive the deductible for fallwithin the "Physician/Practitioner services including doctor's office visits" and "Outpatient Diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to out-of-network office visits and x-rays. This cost sharing is a contractual obligation that had not been met at the time the office visit and x-rays were received on July 31, 2019.Therefore, we decided that the Plan does not have to waive the deductible forthe office visit and x-rays provided on July 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth #30.
You asked the Plan to pre-approve the dental service. You say that The Plan denied your request. The Plan says the crown for tooth #30 is not medically necessary. The Plan also says that tooth #30 does not have significant breakdown that would warrant a crown.
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 service 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 service. Our reviewer says that the requested service is not medically necessary. Our physician reviewer found the enrollee's dental record and radiographs indicate the presence of a one surface restoration in tooth #30. The reviewer found the record does not indicate any fracture or recurrent caries. Therefore the requested service is not medically necessary. 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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth #30.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 23, 2019 by an out of network (OON) provider.You asked the Plan to pay forlaboratory testing. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provideris out-of-network with the Plan and the ordering physician is also out-of-network with 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on January 23, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression stockings identified with code A6531.
You asked the Plan to pre-approve the compression stockings. You say that the compression stockings should be covered. The Plan denied your request. The Plan says you do not have a qualifying diagnosis.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. We looked at the file and Medicare rules. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Based on this information, we decided that Medicare rules for coverage of the compression stockings have not been met. Therefore, we decided that the Plan does not have to pre-approve gradient compression stockings identified with code A6531.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lorazepam 0.5mg tablets.
You asked the Plan to pre-approve Lorazepam. You say that the drug is medically necessary. The Plan denied your request. The Plan says self-administered drugs of this type are not eligible for coverage under the Part B medical benefit.
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 Lorazepam 0.5mg tablets.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe excision of maxillary torus palatinus and removal of torus palatinus.You asked the Plan to pre-approvethe excision of maxillary toruspalatinus and removal of torus palatinus. You say that you need these services done so that you can get dentures.The Plan denied your request. The Plan says Medicare does not cover these services and therefore these services are not covered by 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.Therefore, we decided that the Plan does not have to pre-approvethe excision of maxillary torus palatinus and removal of torus palatinus.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5660) and the addition of a clasp to an existing partial denture (D5650) provided on September 25, 2019.
You asked the Plan to pay for the dental services. You say that you thought you had dental care. You say that you cannot afford dental care. The Plan denied your request. The Plan says denture adjustments are not listed as covered services.
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 denture adjustments that you received are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the addition of a tooth to an existing partial denture (D5660) and the addition of a clasp to an existing partial denture (D5650) provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic evaluation rendered to you on February 6, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 99397 is not covered.The Plan must follow Medicare rules. The rules say that a status indicator of N represents a non-covered service. The services at issue are a periodic comprehensive preventive medicine evaluation billed with code 99397. This code has a status indicator of N and is not covered by Medicare.Therefore, we decided that the Plan does not have to pay forthe periodic evaluation rendered to you on February 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fora screening prostate specific antigen (PSA) test provided on November 5, 2019.You asked the Plan to pay forscreening PSA test. You say that you should have been notified that you had already used your PSA benefit, and you cannot afford this charge.The Plan denied your request. The Plan says the denial of payment for this service is correct, because you received a screening PSA test on April 1, 2019 and therefore the benefit was exhausted at the time this test was performed.The Plan must follow Medicare rules. Medicare rules say that screening prostate specific antigen (PSA) tests are covered once every 12 months for men who have attained age 50. We looked at the file and Medicare rules. A screening PSA test was provided to you on April 1, 2019; therefore 12 months had not passed before this test was performed. Based on this information, we decided that Medicare rules for coverage of screening PSA test have not been met.Therefore, we decided that the Plan does not have to pay fora screening prostate specific antigen (PSA) test provided on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 10, 2019.
You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan denied your request. The Plan says the 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea custom breast prosthesis (HCPCS L8035) for the enrollee.You asked the Planto pre-approvethe custom prosthesis. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a Medicare-covered service.The Plan must follow Medicare rules. Medicare rules say that a custom fabricated breast prosthesis is not considered medically reasonable and necessary by Medicare. The requested custom prosthesis is statutorily not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of the custom prosthesis have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea custom breast prosthesis (HCPCS L8035) for the enrollee