Persius/hicric huggingface dataset:
Appeal type: Other
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 enrollee wants to be able to return to his home at his prior level of function. You say that the enrollee meets the IRF admission criteria under CMS guidelines.The Plan denied your request. The Plan says the records do not indicate that the enrollee meets the criteria for coverage of IRF care.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of 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 level of endurance or functional level 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that on the date of service you began to experience shortness of breath and your heart rate felt elevated. You called and spoke to a nurse who insisted that you call an ambulance due to your symptoms. The responders came and checked you over and also insisted that you go to the emergency room. You say that you asked your sister to take you to the hospital. You say that you decided to go by personal vehicle to save the insurance money. You stated that you don't think that the claim should be denied.The Plan denied your request. The Plan says these services are not a covered benefit.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 December 23, 2019. 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 fortheambulance services.
Appeal type: Practitioner Services
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 October 24, 2019.
You asked the Plan to pay for the services. 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 October 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on December 2, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that you cannot turn away specimens for lab testing as the results are crucial  to the enrollee's care.The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 lab 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 OON services. Therefore, we decided that the Plan does not have to pay forthe lab services provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 18, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on October 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on October 3, 2019.
You asked the Plan to waive the copay for the ambulance transport. You say that this copayment is higher than normal. The Plan denied your request. The Plan says that you are responsible for your copayment.
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 $290 copay for each Medicare-covered one-way trip via ground ambulance. You have been asked to pay a $290 copay for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way trip via ground ambulance 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 copay for the ambulance transport provided on October 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on September 18, 2019, October 7, 2019 and October 14, 2019.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says there is no valid referral for this service.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 servicesat 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 a domiciliary, rest home visit provided on September 18, 2019, October 7, 2019 and October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 20, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 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 physician's services provided on December 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the colonoscopy services you received on November 26, 2019.
You asked the Plan to waive the copay for the services provided. You say that you were not told there would be a charge. The Plan denied your request. The Plan says the copay was applied correctly based on the services provided.
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 copay for outpatient surgery.
You received a colonoscopy. The records show that polyps were removed during your procedure. Your contact says that an outpatient surgery cost share will apply when a polyp removal is conducted. You have been asked to pay a $200 copay for the services provided. The services fall within the outpatient surgery 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 copay for the colonoscopy services you received on November 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide Additional mileage.
You asked the Plan to provide the additional mileage. You say that you exceeded your benefit limit. The Plan denied your request. The Plan says you exceeded your benefit limit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of routine transportation have not been met. You are requesting an additional 314 miles for a total of 389 miles. Your benefit only allows seventy-five (75) miles. You have exceeded your benefit limit. This request is not covered by your health plan. Therefore, we decided that the Plan does not have to provide Additional mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the maxillary partial denture and mandibular partial denture provided on December 12, 2019.You asked the Plan to pay for the maxillary and mandibular partial dentures. You say that trying to eat without your back teeth was affecting your general health. You also say that you desperately needed these dentures.The Plan denied your request. The Plan says your $500 benefit was applied to your previous dental visits, and the remainder of $39.00 was paid towards this visit on December 12, 2019, with the remainder being denied as your benefit was 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, the Plan offers a $500 annual dental benefit limit. The record shows that you met the annual maximum benefit on December 12, 2019 and your annual maximum benefit had been exhausted.Therefore, we decided that the Plan does not have to pay for the maxillary partial denture and mandibular partial denture provided on December 12, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to enrollee on November 9, 2019 by an out of network (OON) provider.You asked the Plan to pay for the out-of-network services. You say that the physician depends on the hospital staff to verify eligibility and to obtain the proper authorization.The Plan denied your request. The Plan says authorization for out-of-network services was not 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay forthe medical services provided to enrollee on November 9, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical nutrition therapyservices you received from September 23, 2019 to October 28, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says you did not meet the coverage criteria for the provided services.The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that you suffer from renal disease or diabetes.Based on the information provided, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay forthe medical nutrition therapy services you received from September 23, 2019 to October 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 23, 2019.You asked the Plan to pay for the subsequent nursingfacility care. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the servicesat 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 subsequent nursing facility care provided on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the annual physical exam provided on
December 18, 2019.
You asked the Plan to waive the coinsurance for the annual physical exam. You say that you should not be
responsible for any payment because your doctor is in-network and have been seeing her for many years. You
say you would not have gone to an out-of-network provider. 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 30% of
the allowed amount for an out-of-network annual routine physical exam.
You have been asked to pay $120 which is 30% of the allowed amount for the annual physical exam. The
allowed amount is $400. ($400 x 30% = $120). The annual physical exam falls within the "Annual routine
physical exam" benefit category. The record shows the provider is out-of-network.
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 coinsurance for the annual physical exam provided on December 18, 2019.
Appeal type: Surgery
Decision: Partially Favorable

You asked the Plan to waive the copayment foresophageal function test. You say that this was not surgery and you should be responsible for a lower out-of-pocket charge.The Plan says that the copayment amount you are being charged is correct.We decided that the Planhas to reduce the copayment foresophageal function test.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 says that you must pay $75 copayment for each in-network diagnostic procedure and test.The Plan says that you must pay $300 copayment for diagnostic test. Based on the Plan contract, however, you cannot be asked to pay more than $75 copayment for diagnostic test.Therefore, we decided that the Plan has to reduce the copayment amount foresophageal function testfrom $300 to $75. We also decided that the Plandoes not have to waive the copayment foresophageal function test. 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 $75 copayment for in-network esophageal function test.Therefore, we decided that the Plan does not have to waive the copayment foresophageal function test.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound provided on November 22, 2019.You asked the Plan to waive the copayment for the ultrasound. You say that diagnostic tests at a specialist office are $40. You say that the bill should be corrected.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 $95 copayment for basic radiological services at an in-network outpatient hospital. You have been asked to pay a $95 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the ultrasound was billed by the hospital. 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 ultrasound provided on November 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crown-porcelain/ceramic substrate tooth 12 (D2740).
You asked the Plan to pre-approve the dental service. You say that a crown is needed to prevent further breakage and loss of the tooth. The Plan denied your request. The Plan says the x-rays provided do not show that this service is medically necessary.
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 this enrollee does not meet the medically necessary criteria for the requested crown. Our physician reviewer found in this instance, the amount of compromised tooth structure is minimal, with one existing involved surface and a second if the mesial is restored with no cuspal damage. The facial abrasion lesion is not from caries or trauma and does not structurally compromise the tooth. Given the clinical appearance of tooth #12, there is no medical necessity for a crown. 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 crown-porcelain/ceramic substrate tooth 12 (D2740).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not haveto pre-approveProlia 60mg/ml syringe for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthe formulary alernatives are intravenous biphosponates (alendronate, risedronate, and zoledronic acid).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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the available documentation does not support that an IV biphosphonate such as Zoledronic acid 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 the drug have not been met.Therefore, we decided that the Plandoes not haveto pre-approveProlia 60mg/ml syringe for the enrollee