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

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of LTACH care.
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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided medical records the acute care hospital is able to provide all of the services the enrollee required. The enrollee was receiving necessary services and was at an appropriate level of care in the acute care hospital. Continued care at that level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health services. The enrollee's status after the reported June 3, 2020 discharge from the hospital against medical advice is unknown. 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-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0651).
You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee failed conservative therapy for support garments, leg elevation, and cannot exercise due to the swelling, and the swelling is very painful. The Plan denied your request. The Plan says the lymphedema must be documented to be unresponsive over the course of the four-week trial.
The Plan follows Medicare rules. The rules state that a PCD coded as E0651 is covered for the treatment of lymphedema after a four-week trial of conservative therapy demonstrating failed response to treatment with compression bandages, elevation, and exercise with detailed assessment done by the prescribing physician at the beginning or end of a four-week trial. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of conservative therapy. Additionally there were no detailed assessment done by a physician including measurements before and after the four-week trial. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0651).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided on December 19, 2019 by an out of network (OON) provider.
You asked the Plan to pay for genetic testing. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the referring provider is also out-of-network. The Plan says that the member's primary care physician did not refer 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 for genetic testing provided on December 19, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the tissue exam provided on November 26, 2019.
You asked the Plan to waive the deductible for the tissue exam. You say that previous lab work has always been paid. 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 in-network deductible is $300. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. Until you have paid the in-network deductible amount, you must pay the full cost of your covered in-network services. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $300 deductible applies to pathology services. This cost sharing is a contractual obligation that had not been met at the time the tissue exam was received on November 26, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the tissue exam provided on November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oral herbal supplements (A9270) to be provided from an out of network provider.
You asked the Plan to pre-approve oral herbal supplements. You say that you are requesting out of network coverage because there is no other provider available to treat your condition. The Plan denied your request. The Plan says the requested herbal treatments are not covered by Medicare or the plan.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pre-approve the oral herbal supplements (A9270) to be provided from an out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on January 3, 2020.
You asked the Plan to waive the copayment for the MRI. You say that the test was inconclusive. You say that you will not pay for this. 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 $200 copayment for diagnostic radiology other than CT scans from an in-network provider. You have been asked to pay a $200 copayment for the MRI. The MRI 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 the MRI provided on January 3, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on October 2, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford the 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 $175 copayment for ambulance services. You have been asked to pay a $175 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network hematologist.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network hematologist.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the hospital outpatient visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says utilization of network providers is required when possible and available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on December 13, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, prophylaxis, and resin-based composite provided on June 10, 2019 and June 20, 2019 by an OON provider.
You asked the Plan to pay for the periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, prophylaxis, and resin-based composite. You say that you have been receiving dental treatment from this provider for years. You also say that this provider knows your history and how to treat your teeth. The Plan denied your request. The Plan says the treating provider is non-contracted with your plan. The Plan also says that services from non-contracted providers are excluded.
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 covered when they are received OON. The Plan confirmed that you did not contact the Plan to verify your dental benefits or to inquire about this provider's network status prior to receiving your dental services. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation, first intraoral periapical x-ray, additional intraoral periapical x-ray, prophylaxis, and resin-based composite provided on June 10, 2019 and June 20, 2019 by an OON provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on March 16, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the 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 $25 copayment for advanced imaging services. You have been asked to pay a $25 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 March 16, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that moving the enrollee to an LTACH facility is the best option because it would free up a bed in the hospital and because a SNF is not going to be sufficient for how sick he is. The Plan denied your request. The Plan says that the information provided does not show that the requirements for coverage of LTACH care have been met. The Plan says that the services needed could be provided in another setting.
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 LTACH services. Our reviewer says that long term acute care hospital (LTACH) services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted to the acute care hospital on May 7, 2020 with shortness of breath. He had acute respiratory decline with x-ray changes, and tested positive for COVID-19. As of May 30, 2020, the enrollee continued with high oxygen requirements, especially with activity. The enrollee was tachypneic, with increased work of breathing, occasional wheezing, and course breath sounds. The enrollee has a right axillary vein thrombosis and blood loss anemia. The documentation in the case file supports that the enrollee requires continued acute care. We looked at this physician's review, the file, and Medicare rules. In addition, we confirmed that the issue with bed capacity was due to COVID-19. CMS published a statement that during the COVID-19 pandemic, long-term acute-care hospitals can now accept any acute-care hospital patients. Based on this information, we decided that Medicare rules for coverage of the LTACH services have been met. Therefore, we decided that the Plan has to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a computer-assisted surgical navigational procedure (20985) provided on November 19, 2019.
You asked the Plan to pay for a computer-assisted surgical navigational procedure. You say that this should be reprocessed. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that CPT 20985 is not covered. We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we decided that Medicare rules for coverage of a computer-assisted surgical navigational procedure have not been met. Therefore, we decided that the Plan does not have to pay for a computer-assisted surgical navigational procedure (20985) provided on November 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for multiple inpatient hospital admissions provided from October 10, 2018 to
November 6, 2018, November 11, 2018 to November 13, 2018, November 25, 2018 to November 27, 2018 and December 5, 2018 to December 12, 2018.
You asked the Plan to pay for the inpatient hospital admissions. 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 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 did not pre-approve the inpatient hospital admissions. 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 multiple inpatient hospital admissions provided from October 10, 2018 to November 6, 2018, November 11, 2018 to November 13, 2018, November 25, 2018 to November 27, 2018 and December 5, 2018 to December 12, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom Continuous Glucose Monitoring System.
You asked the Plan to pre-approve a continuous glucose monitor. You say that testing is difficult and very painful. The Plan denied your request. The Plan says you are not insulin treated by injection or pump, or testing four or more times a day.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records show you are not on insulin. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom Continuous Glucose Monitoring System.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the enrollee needs incontinence wipes. The Plan denied your request. The Plan says these items are non-covered hygienic items.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the total electric hospital bed (E0297).
You asked the Plan to pre-approve the total electric hospital bed. You say that you never asked for a total electric hospital bed. You are open to any suggestions that would raise the bed deck height up to 30-35' so caregiver does not get back problems with total assist patient The Plan denied your request. The Plan says a total electric hospital bed is not covered.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve the total electric hospital bed (E0297).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the osseous surgery (D4261), the bone replacement graft (D4263), the biological materials (D4265), and the guided tissue regeneration (D4266) provided on January 15, 2020 by the out of network provider.
You asked the Plan to pay for the dental services. You say that the provider's office was listed on the website as an in-network practice. You also say that you did not want to start over with a new provider. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan also says dental services that you receive out of network are not covered.
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, your benefit requires you to use a network dentist for the supplemental dental benefits. The record shows that during a phone call with the Plan on January 14, 2020, you were advised that the provider in this case was out of network and the services would not be covered. Therefore, we decided that the Plan does not have to pay for the osseous surgery (D4261), the bone replacement graft (D4263), the biological materials (D4265), and the guided tissue regeneration (D4266) provided on January 15, 2020 by the out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a laryngoscopy provided on January 17, 2020.
You asked the Plan to waive the copayment for a laryngoscopy. You say that you did not receive services in an operating room and disagree with the 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay the allowed amount of $176.21, which is less than the $250 copayment for a laryngoscopy. A laryngoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a laryngoscopy provided on January 17, 2020.