Persius/hicric huggingface dataset:
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 August 7, 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 August 7, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laryngoscopy provided on November 21, 2019.
You asked the Plan to waive the copayment for the laryngoscopy. You say that you received this service in the doctor's office and you had already paid your copayment for the visit. 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 $295 copayment for all other outpatient services including observation and outpatient surgical services not provided in an ambulatory surgical center. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $295 copayment for the laryngoscopy.
You have been asked to pay a $146.10 copayment for the laryngoscopy. The laryngoscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows you were billed by the outpatient 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 for the laryngoscopy provided on November 21, 2019.
Your complaint about the hospital filing false claims 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nocdurna.You asked the Plan to pre-approveNocdurna. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Nocdurna is not covered by the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveNocdurna.Benefits for Nocdurnamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee from November 20, 2018 to January 17, 2019.You asked the Plan to pay for these services. You say that these claims should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan mus tpay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The 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 physician services provided to the enrollee from November 20, 2018 to January 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior authorization 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 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 April 18, 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 services provided to enrollee on September 30, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the nursing home is responsible for obtaining prior authorization.The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and requires 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 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 medical services provided to enrollee on September 30, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forchiropractic services provided on November 18, 2019 to December 3, 2019 by an out of network (OON) provider.You asked the Plan to pay forchiropractic 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 forchiropractic services provided on November 18, 2019 to December 3, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator trial (63650).You asked the Plan to pre-approvethe trial. You say that you would like reconsideration as this service is medically necessary.The Plan denied your request. The Plan says the member is not shown to have exhausted other viable treatment options.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 trial. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found None of the recommendations in the reporthave been trialed. The member's medications are not at maximum dosages or where side effects preclude further escalation. There is no documentation of recent Physical Therapy or Physical Medicine trials.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 trial have not been met.Therefore, we decided that the Plan does not have to pre-approvea spinal cord stimulator trial (63650).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial.
You asked the Plan to pre-approve these services. You say that you are not able to do daily activities due to pain. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an SCS trial is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have chronic leg pain. There is no documentation of a spinal injection for pain relief. There is no documentation of physical therapy or a psychological/psychiatric evaluation or other multispecialty consultation for the SCS. The criteria for coverage are not met and the SCS is not reasonable or medically 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora meningococcal vaccine provided on November 25, 2019.You asked the Plan to pay fora meningococcal vaccine. You say that your doctor recommended this vaccine.The Plandenied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a meningococcal vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a meningococcal vaccine.Therefore, we decided that the Plan does not have to pay fora meningococcal vaccine provided on November 25, 2019.Benefits for a meningococcal vaccinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve implantation of spinal neurostimulator electrodes.
You asked the Plan to pre-approve the implantation. You say that this is medically necessary. The Plan denied your request. The Plan says the correct information was not received.
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 implantation. Our reviewer says that the requested implantation is not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, you have been recommended to undergo spinal cord stimulator placement. This treatment modality is generally recommended as a "last line" treatment approach when other treatment modalities have been exhausted/not feasible. In this case, your pain is noted to be radicular pain. There was no indication that you had previously undergone surgery for your condition, which may be curative. Nor was there an indication that you have otherwise been seen by a surgical provider who indicated that surgery is not an option. In this setting, the spinal cord stimulator cannot be determined to be a last resort treatment. 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 implantation have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of spinal neurostimulator electrodes.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe podiatry services (99334, 11721, 11055) provided on October 28, 2019 by an out of network (OON) provider.You asked the Plan to pay forpodiatry services. You say that there should be an authorization on file for all services provided at the nursing home.The Plan denied your request. The Plan says these 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe podiatry services (99334, 11721, 11055) provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl.You asked the Plan to pre-approve Fentanyl. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Fentanyl is not covered under the enrollee's Medicare Part B benefit.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveFentanyl.Benefits for Fentanylmay be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was unable to ambulate. The enrollee required maximum assistance times two for bed mobility. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF level of care.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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex spacer (22869).
You asked the Plan to pre-approve the Vertiflex spacer. You say that there is significant data indicate the medical necessity of this device. The Plan denied your request. The Plan says medical studies have not proven that the device is helpful for the treatment of the member's condition.
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 Vertiflex spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental and more research is needed. 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 Vertiflex spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex spacer (22869).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on December 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. 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 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 for the medical services provided to the enrolle on December 2, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture.You asked the Plan to pre-approve the complete mandibular denture. You say that you would like bottom dentures so you can chew food and eat.The Plan denied your request. The Plan says this procedure exceeded the frequency limitation for this plan.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, you are limited to 1 complete or partial denture every 5 years. The record shows that you received a mandibular partial denture on August 15, 2016 and your complete or partial dentures benefit is now exhausted.Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 24, 2019 to November 22, 2019. You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not have daily skilled nursing or rehabilitation needs that required an inpatient stay at a SNF. 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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 24, 2019 to November 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cleaning provided on November 13, 2019.
You asked the Plan to pay for the cleaning. You say that you may not have gone there if you were informed the dental office had been excluded from Medicare. You say that you should be paid the maximum payment. The Plan denied your request. The Plan says the cleaning is denied because the provider opted out of Medicare.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit when received from a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the cleaning provided on November 13, 2019.