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

We decided that the Plan does not have to pay for the four extractions provided on August 20, 2019.
You asked the Plan to pay for the 3 extractions. You say that you were informed that everything would be covered at 50%. You also say that you were told you would only owe $240 for one filling and 4 extractions, and were surprised the next time you went and they told you that you now owed more money. The Plan denied your request. The Plan says they issued their obligated 50% coinsurance for one tooth extraction and denied the remaining three tooth extractions in accordance with your optional supplemental dental 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, extractions are limited to one per year. The contract clearly shows that the Plan is only obligated to pay a 50% coinsurance for one simple extraction per year, and you must pay the remaining 50% coinsurance for one simple extraction. The record shows that you received 4 extractions on August 20, 2019, therefore exhausting your extractions benefit limitation of 1 extraction per year. Therefore, we decided that the Plan does not have to pay for the four extractions provided on August 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total electric hospital bed (E0265).
You asked the Plan to pre-approve the hospital bed. You say that you need a new hospital bed because you cannot get on a regular bed and you believe that this should be covered. The Plan denied your request. The Plan says this enrollee does not meet the medical necessity criteria.
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 total electric hospital bed (E0265).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the
enrollee's acute care is being properly managed in the current hospital.
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 physician
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a breast
abscess and end-stage renal disease. The enrollee has undergone a partial mastectomy and is receiving her
routine hemodialysis. The enrollee was transiently intubated/ventilated, but is no longer intubated/ventilated.
As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the
enrollee to the LTACH.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the hyaluronan injection and arthrocentesis
provided on August 6, 2019.
You asked the Plan to waive the cost share for the hyaluronan injection and arthrocentesis. You say that the bill
should only be a $35 copayment. The Plan denied your request. The Plan says the cost share 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 20%
coinsurance for each Medicare-covered Part B drug and a $35 copayment for services obtained from an in-network
specialist.
You have been asked to pay a total of $622.35 for the arthrocentesis and hyaluronan injection.
The hyaluronan injection falls within the "Medicare Part B Prescription Drugs" benefit category. The
arthrocentesis 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 cost share for the hyaluronan injection and arthrocentesis
provided on August 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (D9310) and extraction (D7210) to be performed by an oral surgeon.
You asked the Plan to pre-approve a consultation and extraction. You say that the services need to be performed by an oral surgeon due to the condition of the tooth. The Plan denied your request. The Plan says the provider is not a participating general dentist. Therefore, coverage criteria has not been met.
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 a consultation and extraction when the services are performed by a participating general dentist. We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a consultation and extraction have not been met. Therefore, we decided that the Plan does not have to pre-approve a consultation (D9310) and extraction (D7210) to be performed by an oral surgeon.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested admission to an IRF does not meet criteria. Our physician reviewer found the enrollee was admitted for an elective carcinoembryonic antigen (CEA) on 1/17/2020, complicated by a stroke. The records indicate the enrollee has mobility and activities of daily living deficits following this neurological event. The enrollee has history of rotator cuff repair. He has mild diastolic heart failure. He is hemodynamically stable, and minimal/moderate assist overall for mobility, activities of daily living and transfers. He is walking 20' with use of a walker. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly moderate/minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 3, 2019 by an out of network provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reconsidered for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these 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 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 May 3, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 5, 2019 by the out of
network provider.
You asked the Plan to pay for ECG monitoring. You say that due to our referral from a participating provider,
you would like this claim reconsidered and approved for payment. The Plan denied your request. The Plan says
no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment forthe arthrocentesis provided on March 25, 2019.You asked the Plan to reduce the copayment forthe arthrocentesis. You say that the bill for $225 is an error and you should only be charged a $30 copayment. The Plandenied 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 $225 copayment for Medicare-covered surgery or other services provided at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $225 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows you received this service in an outpatient hospital facility.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 reduce the copayment forthe arthrocentesis provided on March 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 15, 2019 by out of network provider.You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment.The Plandenied your request. The Plan says the referring nursing home is out-of-network. The Plan says that no prior authorization was obtained for these 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 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 medical services provided on August 15, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that theenrollee needs to regain prior level of functioning with a continued multi-disciplinary approach to care.The Plan denied your request. The Plan says ongoing acute care needs are being met at the current acute care 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 physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for osteomyelitis of her ankle. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH.We looked at this physician's review, the file, and Medicare rules. Based onthis information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services forthe enrollee.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveuse of Prolia (denosumab).You asked the Plan to pre-approveProlia. You say that the enrollee has tried and failed Fosamax.The Plan denied your request. The Plan says that the denial of authorization for Prolia is correct, because the enrollee must have a history of osteoporotic fracture or have had previous treatment, contraindication, or intolerance to the Plan's preferred drug of Zoledronic Acid before the Plan will approve Prolia.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 therelevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that the enrollee meets the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found it is documented that the enrollee has failed treatment with a bisphosphonate, therefore the Plan's preferred drug of Zoledronic Acid would likely be less effective for the enrollee and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have been met.Therefore, we decided that the Plan has to pre-approveuse of Prolia (denosumab).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 to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity.You asked the Plan to pre-approve Trulicity. You say that the enrollee has tolerated and is responding well to the medication.The Plan denied your request. The Plan says drug coverage is limited to Part B covered drugs.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-approveTrulicity.Benefits for Trulicity may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient hospital stay provided from June 20, 2019 to June 24, 2019.You asked the Plan to waive the copayment forthe inpatient hospital stay. You say that this hospital stay should be a continuation of the first hospital stayfrom June 11, 2019 to June 17, 2019. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $395 copayment for each day for days 1-4 for Medicare-covered hospital care. The enrollee has been asked to pay a $395 copayment for each day the inpatient hospital stay. ($395 x 4 days = $1,580). The inpatient hospital stay falls within the "Inpatient Hospital Care" benefit category. 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 forthe inpatient hospital stay provided from June 20, 2019 to June 24, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the catheter removal procedure provided on August 6, 2019.You asked the Plan to waive the coinsurance for the catheter removal procedure. You say that you should not be charged this amount because you were not in an operating room. You say you were told there would be no charge for the service. 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 15% of the total cost of the service up to $200 for each Medicare covered in-network outpatient hospital service. You have been asked to pay $88.85 which is 15% of the allowed amount for the catheter removal procedure. The allowed amount is $592.33. ($592.33 x 15% = $88.85). The catheter removal procedure falls within the "Outpatient hospital services" benefit category. The record shows you had this procedure done at an 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 coinsurance forthe catheter removal procedure provided on August 6, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forspecialist services provided on May 20, 2019 to July 16, 2019.You asked the Plan to waive the copayments for dermatology services. You say that you were not charged a copayment for any of these office visits before. You say that you would like these copayments waived.The Plan denied your request. The Plan says the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a$10 copayment for physician/practitioner services/specialist office visit. You have been asked to pay a $10 copayment each for dermatology services. Dermatology office visits are considered specialist services. The total amount you are being asked to pay is $70 ($10 x 7 visits = $70). Dermatology services falls within the physician/practitioner services/specialist office visit 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 forspecialist services provided on May 20, 2019 to July 16, 2019
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. 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-approvefoot orthotics.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Electroencephalogram (EEG) during non intracranial surgery (95955).
You asked the Plan to pre-approve Electroencephalogram (EEG) during non intracranial surgery (95955). You say that the requested EEG is medically necessary. The Plan denied your request. The Plan says the requested EEG is not medically necessary.
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 Electroencephalogram (EEG) during non intracranial surgery (95955). Our reviewer says that the requested EEG is not medically necessary. Our physician reviewer found the enrollee is approved for L4-5 TLIF with instrumentation and decompression at L5-S1. The plan approved intraoperative EMG monitoring and continuous intraoperative neurophysiology monitoring and neuromuscular junction testing and a 2 day inpatient hospital stay. In this case, EEG is not needed during routine spine surgery, as it is not medically necessary for the surgery. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Electroencephalogram (EEG) during non intracranial surgery (95955) have not been met. Therefore, we decided that the Plan does not have to pre-approve Electroencephalogram (EEG) during non intracranial surgery (95955).