Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve infusions of ketamine.
You asked the Plan to pre-approve ketamine. You say that the benefits of this drug outweigh the negatives. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because you do not meet the Medicare criteria for use of this drug.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 ketamine. Our reviewer says that you do not meet the Medicare criteria for the requested drug. Our physician reviewer found there is some evidence that ketamine has been used off-label for the treatment of your condition. However, this use is not well studied in those over 65 years old and it is not recommended. The documentation does not support the use of the requested ketamine for treatment of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of ketamine have not been met. Therefore, we decided that the Plan does not have to pre-approve infusions of ketamine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on January 27, 2020.You asked the Plan to waive the copayment for the office visit. You say that this is the first time you received a bill. You say that you shouldn't be responsible.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 $15 copayment for each primary care doctor office visit for Medicare-covered services. You have been asked to pay a $15 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on January 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee.You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that this is not covered for use outside of the home.The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approve a power wheelchair and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on December 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for skilled nursing services provided on December 5, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an epidurogram.
You asked the Plan to pre-approve the epidurogram. You say that the enrollee has been approved for the facet joint injections and needs to have this imaging done as well. The Plan denied your request. The Plan says there is no reason for this imaging to be done with the injections.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the epidurogram. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this patient has chronic low back pain without radiculopathy. The patient is scheduled for facet joint injections. The request is for epidurography. The patient does not have a history of significant scoliosis, past spine surgery with epidural adhesions or other significant anatomic abnormalities. There is no plan for additional surgical therapeutic interventions that are dependent on the result of this imaging. As there is not a clear indication for this imaging, it is not considered reasonable and 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 epidurogram have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidurogram.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full Fee Schedule amount for the endosteal implant (D6010), the extraction (D7210), and the bone replacement graft for ridge preservation (D7953) provided on November 12, 2019.
You asked the Plan to pay the full Fee Schedule amount for the dental services. You say that you knew the balance of your coverage would not be enough to cover the services that you received. You say that a plan representative confirmed that the services you were scheduled to receive would be covered, but did not mention that there would not be a write-off. You say that the Evidence of Coverage, on page 98, did not say "no write-off" either. You also say that you should be compensated for the overcharge of $902 due to the ambiguity of the statement in the Evidence of Coverage. The Plan denied your request. The Plan says the annual maximum for comprehensive dental services is $1,000. The Plan says that when a service is denied due to the benefit being exhausted, you are responsible for the entire billed amount.
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 annual maximum of $1,000 has been exhausted.
Additionally, the Evidence of Coverage clearly states that you are responsible for any amounts beyond the benefit limits. The record shows that the Plan paid the full amount for the guided tissue regeneration. The benefit maximum was reached in the processing of the implant. Therefore, we decided that the Plan does not have to pay an additional amount for the endosteal implant (D6010), the extraction (D7210), and the bone replacement graft for ridge preservation (D7953) provided on November 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery back-up device.
You asked the Plan to pre-approve the back-up. You say that this is medically necessary during electrical power outage periods. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a battery back-up device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a weight attachment for a Hoyer lift (E1399).
You asked the Plan to pre-approve a weight attachment for a Hoyer lift. You say that if there is another way to weigh a total assist patient at home you will accept, however a Hoya lift weighing attachment would be the easiest, most appropriate, and most cost effective. The Plan denied your request. The Plan says this item does not treat a medical condition so this i not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a weight attachment for a Hoyer lift (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on February 10, 2020.
You asked the Plan to pay for the dental service. You say that your dentist did not explain to you that you already had this done. The Plan denied your request. The Plan says 1 comprehensive oral evaluation is covered every 36 months. The Plan also says that the frequency limit has been exceeded.
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 and comprehensive oral evaluations are a covered service, the frequency limit has been exceeded. The record shows that the Plan previously paid for a comprehensive oral evaluation that you received on July 24, 2019. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on January 15, 2020.
You asked the Plan to waive the deductible for the office visit. You say that you were informed your copayment would be $18. 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 combined in-network and out-of-network deductible is $185. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the combined deductible amount, you must pay the full cost for most of your covered services. The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $185 deductible applies to office visits. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on January 15, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical extraction (D7210) for tooth #15.
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says the x-rays from January 13, 2020 show that tooth # 15 is not present.
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 service is not medically necessary. Our physician reviewer found tooth # 15 has drifted mesially as can be discerned by the marginal ridge height discrepancy on the provided bitewing x-ray. The reviewer found that the tooth is therefore present in the arch. The reviewer also found no indication that a surgical extraction is 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 surgical extraction (D7210) for tooth #15.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on August 26, 2019.
You asked the Plan to pay for train of four testing. You say that this should be manually reprocessed. The Plan denied your request. The Plan says payment of this service is bundled into other services.
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 CPT code 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other intraoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on August 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on February 2, 2020.

You asked the Plan to waive the copayment for the ambulance ride. You say that you were under the impression the ambulance ride would be included in either the skilled nursing facility or the hospital charge. 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 $150 copayment for Medicare-covered one-way ground ambulance benefit. 

You have been asked to pay a $150 copayment for the ambulance ride. The ambulance ride falls 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 the ambulance ride provided on February 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the health club membership fee provided on January 1, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the health club membership fee. The Plan denied your request. The Plan says that services must be provided in-network in order to be eligible for payment.
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 health club membership fee provided on January 1, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (99213, 90836) December 23, 2019 to January 13, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says the provider does not participate in Medicare.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient mental health services (99213, 90836) December 23, 2019 to January 13, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from January 6, 2020 to January 9, 2020.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you should not be responsible for the copayment 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 $350 copayment per admission for in-network inpatient hospital care. You have been asked to pay a $350 copayment for the inpatient hospital stay. The inpatient hospital 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 hospital stay provided from January 6, 2020 to January 9, 2020.
Your complaint about your poor treatment at the hospital is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for cardiac rehabilitation provided from January 3, 2020 through January 31, 2020.
You asked the Plan to waive the deductible for cardiac rehabilitation. You say that you weren't informed of the deductible. You say that you were informed the cardiac rehabilitation would be covered. 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 $750. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. The item or service you asked the Plan to waive the deductible for falls within the "Cardiac rehabilitation services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to cardiac rehabilitation. This cost sharing is a contractual obligation that had not been met at the time the cardiac rehabilitation was received from January 3, 2020 to January 31, 2020. Therefore, we decided that the Plan does not have to waive the deductible for cardiac rehabilitation provided from January 3, 2020 through January 31, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from December 10, 2019 to December 18, 2019.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you should only owe a $10 copayment per each visit 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 $40 copayment for outpatient rehabilitation services. You received outpatient rehabilitation services from December 10, 2019 to December 18, 2019 for a total of 3 visits. Therefore, you are responsible to pay a $40 copayment per each visit. The total amount you owe is: $40 (copayment) x 3 (outpatient rehabilitation services) = $120. You have been asked to pay the total copayment amount of $120 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from December 10, 2019 to December 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on February 15, 2020.
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says that this is not covered without transport.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 15, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on February 15, 2020.