Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and extraction provided on September 12, 2016 and September 22, 2016.
You asked the Plan to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, extraction. You say that the provider does not take your insurance. The Plan denied your request. The Plan says these services are excluded from coverage by your plan.
Medicare generally does not cover dental services. The Plan follows the same rule. The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation, first intraoral periapical x-ray, and extraction provided on September 12, 2016 and September 22, 2016.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided by a participating
provider on December 17, 2019.
You asked the Plan to waive the copayment for an office visit. You say that you never got any help with your
elbow. You say that your copayments are getting more expensive and you are not having any relief. The Plan
denied your request. The Plan says the correct copayment has been applied.
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 $45
copayment for physician/practitioner services/specialist.
You have been asked to pay a $45 copayment for an office visit. Since a specialist office visit was provided the
correct copayment has been applied. An office visit falls within the physician/practitioner services/specialist
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 an office visit provided by a
participating provider on December 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation (E0730).You asked the Plan to pre-approve a TENS device. You say that the device is necessary for your pain management.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that for coverage of a purchase, the treating practitioner must determine that the beneficiary is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time.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 TENS device. Our reviewer says that the item is not medically necessary. Our physician reviewer found in this case, there is no indication prior use of TENS unit therapy (within the context of physical therapy) has resulted in clinically significant improvement in pain scores using validated measures, and/or specific functional improvements including specifically documented positive activities of daily living (ADL's) outcomes. As such, this request is deemed 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 a TENS device have not been met.Therefore, we decided that the Plan does not have to pre-approve a transcutaneous electrical nerve stimulation (TENS) device, four or more leads, for multiple nerve stimulation (E0730).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe requested dental implants and bone grafting (D4266, D6010, D7921, D7952, D7953).You asked the Plan to pre-approvethe dental services. You say that this is a surgical procedure, not a dental procedure.The Plan denied your request. The Plan says these services are not covered under your 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 benefitin excess of Medicare coverage, the requested services are not among those covered under this benefit. The plan covers only those dental services for which the codes are listed in the Evidence of Coverage. The requested implants and grafting services are not listed, and therefore are not covered.Therefore, we decided that the Plan does not have to pre-approvethe requested dental implants and bone grafting (D4266, D6010, D7921, D7952, D7953)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee injection of hyaluronic acid.
You asked the Plan to pre-approve hyaluronic acid injection. You say that you are appealing with medical
records. The Plan denied your request. The Plan says the denial of authorization for this service is correct,
because the submitted documentation indicates that the enrollee does not have osteoarthritis.
The Plan follows Medicare rules. Medicare rules say that hyaluronan injections of the knee are only covered
for osteoarthritic and only when the enrollee meets certain clinical criteria.
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 hyaluronic acid injection. Our reviewer
says that the enrollee does not meet the Medicare criteria for the requested injections. Our physician reviewer
found there is no evidence of arthritis of the right knee and there are minimal changes on the left in the lateral
compartment. The requested hyaluronic injections are not medically reasonable and necessary at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of hyaluronic acid injection have not been met. Therefore, we decided that the
Plan does not have to pre-approve a knee injection of hyaluronic acid.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
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 the requested admission to an IRF is medically necessary.The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.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 admission to an IRF does not meet criteria. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not require intensive physician or nursing supervision in an IRF. The enrollee may benefit from physical therapy and occupational therapy but the documentation does not indicate that the enrollee's functional status requires this on an intensive 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane.You asked the Plan to pre-approve Durolane. You say that the requested Durolane is medically necessary.The Plan denied your request. The Plan says the enrollee must try and fail Monovisc AND Orthovisc first.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 Durolane. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with knee pain and a diagnosis of left knee osteoarthritis, confirmed by x-rays. The enrollee has tried failed conservative treatment. Durolane injection is being requested. The provided medical records do not indicate that the enrollee has tried and failed the required drugs, Monovisc and Orthovisc first. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met.Therefore, we decided that the Plan does not have to pre-approve Durolane.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea bone growth device (E0747).You asked the Plan to pre-approve a bone growth device. You say that the requested item is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that a non-spinal electrical osteogenesis stimulator (E0747) is covered only if specific criteria is met.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 bone growth device. Our reviewer says that the item is not medically necessary. Our physician reviewer found the records do not indicate this request is for home use, and medical criteria for utilization are not satisfied. This is a request deemed 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 a bone growth device have not been met.Therefore, we decided that the Plan does not have to pre-approve a bone growth device (E0747).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe implantation of a spinal neurostimulator provided on January 14, 2020.You asked the Plan to waive the copayment forthe implantation of a spinal neurostimulator. You say that you had to have the device removed and replaced 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 a $250 copayment for an implantation of the spinal neurostimulator. The implantation of a spinal neurostimulator 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 forthe implantation of a spinal neurostimulator provided on January 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on
November 6, 2019.
You asked the Plan to waive the copayment for the laboratory services. You say that you should not have a
copayment since the services were done during your annual physical exam. 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 a $20
copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR
testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are
performed.
You have been asked to pay a $20 copayment for the laboratory services. The laboratory services fall within
the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the
laboratory services are considered a separate service.
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 laboratory services provided on November 6, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 7, 2019 through
May 10, 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 that the stay is not medically necessary.
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 supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the review showed the record showed that at the time of inpatient admission the admitting
physician reasonably expected that the patient's necessary hospital care (including earlier emergency
department (ED) and/or observation care) would span two midnights.
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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided from May 7, 2019 through May 10, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 4, 2019 by an out of network (OON) provider.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 were rendered by an out-of-network provider without prior authorization.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 August 4, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 4, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you had no control over receiving the ambulance ride. 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 clearly says that you must pay a $275 copayment for Medicare-covered ambulance services per day. You have been asked to pay a $275 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance services per day 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 ambulance transport provided on December 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a specialist on May 14, 2019.
You asked the Plan to waive the copayment for a specialist office visit. You say that you do not agree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.
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 physician/practitioner services/in-network/specialist. You have been asked to pay $37.04 which is less than your copayment amount of $40 for a specialist office visit. Since a specialist office visit was provided, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/in-network/specialist 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 office visit provided by a specialist on May 14, 2019.
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 enrollee should be sent to the LTACH for vent weaning. The Plan denied your request. The Plan says there is no documentation of failure to wean. The enrollee can remain in the ICU and receive all necessary 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 Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not provide clinical services that are materially different than those of short term acute care hospitals. The member is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 88112) provided on November 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed twice.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the billing of CPT code 88112 is not supported in the medical record. Specifically, the records show that this procedure was billed twice, once as a global procedure, and once with the professional and technical components. Per Medicare rules, if the professional and technical components are performed by the same provider, then it is not appropriate to report the components separately. Based on this information, we decided that Medicare rules for coverage of the professional and technical components of CPT 88112 have not been met. Therefore, we decided that the Plan does not have to pay for the services (CPT 88112) provided on November 5, 2019.