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

We decided that the Plan does not have to pay for the eyewear purchased from an out-of-network provider from August 6, 2019 through August 11, 2019.

You asked the Plan to pay for the eyewear. You say that you were not aware that you had to go to a specific store to purchase the glasses. The Plan denied your request. The Plan says you do not have out-of-network benefits.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the eyewear have not been met. You purchased eyewear from an out-of-network provider. Your EOC clearly states, you have a choice of:-Eyeglasses or contact lenses and fitting at a network optical provider  (per calendar year). Therefore, we decided that the Plan does not have to pay for the eyewear purchased from an out-of-network provider from August 6, 2019 through August 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
You asked the Plan to pre-approve IMRT. You say that in order to minimize dose to the underlying brain an IMRT plan is required. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because IMRT is not approved for the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that intensity modulated radiation therapy (IMRT) is only covered for certain diagnoses and only when the enrollee meets certain specific criteria. 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 IMRT. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested IMRT. Our physician reviewer found the enrollee is being offered IMRT to target only the sites of disease seen on brain imaging. The appeal offers no evidence to support this proposed treatment. IMRT is only used for hippocampal sparing or partial brain radiation for limited metastases. The eligibility criteria for the published and ongoing studies of hippocampal sparing IMRT excluded patients with the enrollee's condition. The requested IMRT would not fall within the standard of care medical practice. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to pre-approve intensity modulated radiation therapy (IMRT).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the $200 copayment charged for outpatient diagnostic radiology services provided on September 11, 2019.
You asked the Plan to waive the this copayment. You say that this copayment is not correct. The Plan denied your request. The Plan says this copayment was charged based on the services provided and the Plan contract agreement.
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 $200 copayment for outpatient radiology services. 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 $200 copayment charged for outpatient diagnostic radiology services provided on September 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pacemaker evaluation provided on September 26, 2019.
You asked the Plan to waive the copayment for the pacemaker evaluation. You say that you were not made aware that you would be charged a $50 copayment for the pacemaker. 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 $50 copayment for all other diagnostic procedures and tests. You have been asked to pay a $50 copayment for the pacemaker evaluation. The pacemaker evaluation falls 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 copayment for the pacemaker evaluation provided on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. The Plan denied your request. The Plan says there are in-network specialist available in your area.
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 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. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve pain management services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement of nail(s) (11721) provided on July 19, 2019
You asked the Plan to pay for debridement of nail(s). You say that you are appealing the denial of payment for dates of service July 19, 2019. The Plan denied your request. The Plan says the services were rendered without an authorization. The enrollee must receive their care from a network provider. In most cases, care received from an out-of-network provider will not be covered.
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 debridement of nail(s) (11721) provided on July 19, 2019
Please remember that you signed a Waiver of Liability in which you agreed not to bill the enrollee for these services. This Waiver does not, however, deny your right to seek further appeal from an Administrative Law Judge.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued care in the long-term acute care hospital (LTACH).
You asked the Plan to pre-approve the continued LTACH care. You say that the enrollee has just changed insurance and you want to ensure that coverage will continue under the new plan. The Plan denied your request. The Plan says until the enrollee is deemed stable for discharge, coverage of the inpatient stay is the responsibility of the plan in which the enrollee was a member at the time of admission. Therefore, no approval can be provided by the Plan.
The Plan must follow Medicare rules. Medicare rules say that for inpatient hospital care, if coverage with a plan begins while the enrollee is an inpatient, the prior payer is responsible for the stay up until discharge. The enrollee began this admission in January 2019 when he was a member of another plan. That plan remains responsible for coverage of the stay until discharge. Therefore, we decided that the Plan does not have to pre-approve continued care in the long-term acute care hospital (LTACH).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe replace missing or broken teeth -complete denture, extraction, two crowns, and precision attachment provided from April 30, 2019 to June 5, 2019.You asked the Plan to pay forthe replace missing or broken teeth -complete denture, extraction, two crowns, and precision attachment. You say that the creation of a new prosthesis is a necessity that allows you to speak, eat, breathe, and swallow.The Plan denied your request. The Plan says these services are not covered under your Plan benefits.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 pay forthe replace missing or broken teeth -complete denture, extraction, two crowns, and precision attachment provided from April 30, 2019 to June 5, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve rituximab for the enrollee.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has a diagnosis of B-cell chronic lymphocytic leukemia, fatigue, and lymphadenopathy. Rituximab is a reasonable option for this diagnosis. The drug is considered safe and effective for the enrollee, as it can produce a response but expected to be short lived, but for palliation. The rituximab is reasonable and 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 been met. Therefore, we decided that the Plan has to pre-approve rituximab for the enrollee.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy (36475).
You asked the Plan to pre-approve endovenous ablation therapy. You say that this is needed to improve the enrollee's symptoms. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for coverage of this procedure.
The Plan must follow Medicare rules. Medicare rules say that treatment for Symptomatic Chronic Venous Insufficiency may be covered as medically necessary with a documented 3-month trial of conservative therapy including weight reduction to BMI less than 35. We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee has had a 3-month trial of conservative therapy including weight reduction to BMI less than 35. The enrollee's BMI remains above 35. Based on this information, we decided that Medicare rules for coverage of endovenous ablation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy (36475).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from May 14, 2019 to May 16, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that this was medically necessary. The Plan denied your request. The Plan says that you could have been treated in observation.
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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found you presented to the emergency department with increased shortness of breath. On evaluation, your physical exam was notable for an irregular heart rate and trace lower extremity edema. An electrocardiogram demonstrated atrial fibrillation and the chest x-ray showed mild congestive heart failure. You were treated with IV diuretics, evaluated by Cardiology, and admitted. Your condition stabilized and improved with changes in your medical regimen, and you were discharged home when considered medically stable. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that your necessary hospital 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from May 14, 2019 to May 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara prefilled syringes.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing with medical records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that the enrollee's Medicare Part D prescription drug benefits may be administered by Express Scripts.
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-approve Stelara prefilled syringes.
Benefits for self-administered drugs may 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: 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 you had an allergic reaction to a bee sting and passed out. A neighbor called an ambulance however you were feeling better by the time it arrived and you declined transportation. You say that it is unfair that you are being held responsible for the cost of the services. 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 September 15, 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 for the ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 26, 2019 by an out-of-network provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by a non-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 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 July 26, 2019 by an out-of-network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from May 1,
2019 to June 29, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says a valid HIPPS code is required for processing, per Medicare guidelines.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
The claim was not billed with a valid HIPPS code. Based on this information, we decided that Medicare rules
for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for
home health services provided to the enrollee from May 1, 2019 to June 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on September 11, 2019.
You asked the Plan to waive the copayment for the office visit. You say that this was no different than your last few visits. You say that you don't need to pay the $35 copayment. 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 $35 copayment per specialist visit. You have been asked to pay a $35 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on September 11, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided at an alternate 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee's medical needs, medications and status does not require a SNF admission. This enrollee is near functional baseline and does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment only in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this enrollee does not require the necessary services on 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long 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 based on the documentation provided, coverage criteria has not been met.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 enrollee is currently undergoing treatment at an acute care hospital (ACH) for failure to thrive following recent abdominal surgeries. The enrollee is receiving supplemental nutrition. 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. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care (LTC) needs.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture rendered on September 7, 2019.
You asked the Plan to pay for these services. You say that the enrollee has benefits for acupuncture. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have to pay for the acupuncture rendered on September 7, 2019.