Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic manipulative treatment (98940) and the x-ray exam of the lumbar spine (72100) provided by the out of network (OON) provider from November 27, 2019 to December 11, 2019.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the chiropractic services were provided 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 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 forthe chiropractic manipulative treatment (98941) provided by the out of network (OON) provider from November 27, 2019 to December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an air-fluidized bed, patient lift and trapeze equipment.
You asked the Plan to pre-approve these services. You say that these items are medically necessary. The Plan denied your request. The Plan says that you do not meet criteria because you have an existing pulmonary disease.
The Plan must follow Medicare rules. Medicare rules say that an air-fluidized bed will be denied as not reasonable and necessary if the beneficiary has coexisting pulmonary disease. We looked at the file and Medicare rules. The file indicates you have emphysema, a coexisting pulmonary disease. 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 an air-fluidized bed, patient lift and trapeze equipment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehealth club membershipYou asked the Plan to pre-approvehealth club membership. You say that you were told verbally and confirmed in writing that the Renew Fitness Program was in plans 1 and 2 for 2020. You were looking forward to going to the club in January and getting supervised assistance.The Plan denied your request. The Plan says health club membership is not covered under the benefits package.The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits.Therefore, we decided that the Plan does not have to pre-approvehealth club membership
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.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 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 they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. 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 beenmet.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a screening mammogram professional component
You asked the Plan to pay for screening mammogram. You say that this claim is for the physician reading the report that the technician performed on October 1, 2019. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the benefit limit has been exceeded for this service.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules say that, for asymptomatic women over age 39, screening mammograms may be covered after at least 11 months have based following the month in which the previous screening mammogram was performed. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any evidence to support that the benefit limit for this screening mammogram was exceeded at the time this screening mammogram was provided. The medical record shows that a previous screening mammogram was performed in October 2017, therefore at least 11 months had passed before this screening mammogram was performed. The Plan has not provided evidence to support that a screening mammogram was provided less than 11 full months prior to this screening mammogram. Without this information, the Plan has not shown that its denial of payment for this service is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay for a screening mammogram professional componen
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital care
You asked the Plan to waive the copayment. You say that the enrollee should not have to pay the inpatient copayment as you were given the wrong information by the health plan. The Plan denied your request. The Plan says the copayment has been applied correctly according to the enrollee's contractual policy.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment per day, for days 1-5 for inpatient hospital care. The enrollee has been asked to pay a $1500 copayment ($300 x 5 days) for inpatient hospital care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve a total electric hospital bed. You say that you have trouble getting out of your semi-electric bed. The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that the enrollee needs the orthotics for foot pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace that is part of a shoe. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for their condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the enrollee does not require the daily skilled services to be provide only on an inpatient basis in a SNF because it is feasible to meet the enrollee's needs at a lower level of care.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablationtherapy.You asked the Plan to pre-approve the endovenous ablation therapy. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for varicose vein treatment.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services for varicose vein treatment.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the occlusal guard provided on April 2, 2019.
You asked the Plan to pay for the occlusal guard. You say that the enrollee submitted an appeal which was overturned but you never received the payment. You also say that when you called to have another ticket submitted, you were told that the claim was reprocessed when it had been sent back for re-issuance. The Plan denied your request. The Plan says this service is not covered by Medicare.
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 the enrollee's teeth or the structures directly supporting the enrollee's 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 occlusal guard provided on April 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided June 14, 2019 to June 15, 2019.
You asked the Plan to pay for the acute inpatient hospital care. You say that the inpatient hospital care provided was medically necessary. The Plan denied your request. The Plan says the inpatient hospital care provided was 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 the acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee presented to the emergency room on June 14, 2019 with chest pain. He stated he had been having intermittent chest pain for the past week. On evaluation his vital signs were stable, and the physical exam was unremarkable. Laboratory results revealed normal cardiac biomarkers; the chest x-ray was normal, and the electrocardiogram was normal sinus with left bundle branch block. The enrollee was then evaluated by Cardiology and admitted to telemetry. He had an echocardiogram and his condition stabilized and improved. An acute coronary syndrome (ACS) was ruled out and the enrollee was discharged home. The review has determined that the record did not show that at the time of the inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier 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 the acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided June 14, 2019 to June 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for follow-up service
You asked the Plan to pre-approve these services. You say that the enrollee would prefer not to change doctors. The Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network provider for follow-up services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an outpatient consultation to be provided by physicians
You asked the Plan to pre-approve the outpatient consultation. The Plan denied your request. The Plan says the services are available with Plan providers.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing these services and is not making arrangements to provide these services. Therefore, we decided that the Plan does not have to pre-approve an outpatient consultation to be provided by physicians
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the fracture treatment and hand x-rays
provided on November 8, 2019, November 15, 2019 and December 13, 2019.
You asked the Plan to waive the copayments for the fracture treatment and hand x-rays. You say that you
should have been charged for an office visit and x-rays. You say that you want a refund. The Plan denied your
request. The Plan says the copayments 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 $350
copayment for Medicare-covered in-network outpatient surgery services furnished in a physician's office,
certified ambulatory surgical center, hospital outpatient department, or any other location and a $40 copayment
for Medicare-covered in-network x-rays.
You have been asked to pay a total of $258.92 for the fracture treatment and hand x-rays.
Date of Service
Service
Allowed Amount
Standard Copayment
Member Liability
November 8, 2019
Fracture Treatment
$194.58
$350
$194.58
November 15, 2019
Hand X-Ray
$32.17
$40
$32.17
December 13, 2019
Hand X-Ray
$32.17
$40
$32.17
TOTAL:
$258.92
The fracture treatment falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The hand x-rays fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for the fracture treatment and hand x-rays provided on November 8, 2019, November 15, 2019 and December 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of the BiPAP.
You asked the Plan to pre-approve continued use of the BiPAP. You say that you have back pain and the BiPAP machine helps you sleep at night. The Plan denied your request. The Plan says the information provided shows the you are not using the device as prescribed.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at this the file and Medicare rules. The record shows you are not compliant. Based on this information, we decided that Medicare rules for coverage of continued use of the BiPAP have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of the BiPAP.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you need orthotics because of foot pain due to surgery. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740) and post and core in addition to crown (D2952).
You asked the Plan to pre-approve the porcelain/ceramic crown (D2740) and post and core in addition to crown (D2952). You say that you were not informed these would not be covered. You say that the price is more than you can afford. The Plan denied your request. The Plan says the crown exceeds the maximum benefit allowed and the post and core are not a covered benefit.
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. Therefore, we decided that the Plan does not have to pre-approve the porcelain/ceramic crown (D2740) and post and core in addition to crown (D2952).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepersonal attendant services.You asked the Plan to pre-approvepersonal attendant services. You say that you need help getting around, bathing, grooming, preparing your meals, and going to the grocery story.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because custodial care services are not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that custodial care services are not covered by Medicare. We looked at the file and Medicare rules. The services you are requesting are custodial care in nature. Based on this information, we decided that Medicare rules for coverage of personal attendant services have not been met.Therefore, we decided that the Plan does not have to pre-approvepersonal attendant services.