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

We decided that the Plan does not have to pay forout-of-network dental services (D7140, D0330, D0140) provided from July 28, 2020, to July 30, 2020.You asked the Plan to pay forout-of-network dental services. You say that you were told this would be covered.The Plan denied your request.The Plan says the provider of these services is not in-network, so these services are not covered.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, out-of-network services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay forout-of-network dental services (D7140, D0330, D0140) provided from July 28, 2020, to July 30, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for debridement; skin, and subcutaneous tissue
(11042) and multi-level compression bandage application; leg, including ankle and foot (29581) provided
March 5, 2020 to April 3, 2020.
You asked the Plan to waive the copayment for the outpatient surgical services. You say that you wish to
appeal this bill. One visit was to remove stitches. Another was to remove a piece of dead skin and the other
visits were to apply new bandages and dressings not surgery. The Plan denied your request. The Plan says the
claims were processed and the correct copayments were applied per the plan benefits
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 $225
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
You have been asked to pay $1154 ($225 for date of service March 5, 2020 + $127.03 for date of service
March 10, 2020 + $225 for date of service March 13, 2020 + $127.03 for date of service March 17, 2020 +
$225 for date of service March 20, 2020 + $225 for date of service April 3, 2020 = $1154) copayment for the
outpatient surgical services. The outpatient surgical services fall within the Outpatient surgery and other
medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 debridement; skin, and subcutaneous tissue (11042) and
multi-level compression bandage application; leg, including ankle and foot (29581) provided March 5, 2020 to
April 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forinpatient hospital care from March 30 to April 7, 2020 and June 2 to June 3, 2020.You asked the Plan to waive the copayments forthe inpatient hospital care. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct amount was 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 $235 per day copayment for days 1 through 7 of inpatient hospital care.You have been asked to paya $1,410 copayment for a 6 day admission, and then a $235 copayment a one day admission to an inpatient hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is acontractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forinpatient hospital care from March 30 to April 7, 2020 and June 2 to June 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe barium swallow provided in July 21, 2020.You asked the Plan to waive the copayment forthe barium swallow. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.The Plan denied your request. The Plan says you received a barium swallow provided in an outpatient hospital setting on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.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 $250 copayment for Outpatient hospitalservices. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a barium swallow in an outpatient hospital setting on July 21, 2020. You have been asked to pay a $250 copayment for the barium swallow. The bariumswallow falls within the Outpatient hospital services 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 forthe barium swallow provided in July 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient mental health care provided.

You asked the Plan to pay for the inpatient mental health care. You say that the inpatient mental health care provided was medically necessary.The Plan denied your request. The Plan says the inpatient mental health care provided  was not medically necessary.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 

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 inpatient mental health care. Our reviewer says that the inpatient mental health care provided was not medically necessary. Our physician reviewer found based upon review of the records provided the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of April 24, 2018 forward as this enrollee was not shown to be a danger to herself or others. She was not showing 
any auditory or visual hallucinations and was cooperative/compliant with treatment while not showing any threats to safety.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 inpatient mental health care have not been met.Therefore, we decided that the Plan does not have to pay for the inpatient mental health care.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 7, 2020.
You asked the Plan to waive the copayment for laboratory services. You say that you had tests done at the facility inside your doctor's office. You say that you shouldn't have to pay this. 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 $20 copayment for lab services at a freestanding laboratory. You have been asked to pay a $20 copayment for the laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the laboratory services were billed by a freestanding lab. 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 laboratory services provided on August 7, 2020.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approvefacet joint injections.You asked the Plan to pre-approvefacet joint injections. You say that you feel that the enrollee is a great candidate for this treatment.The Plandenied your request. The Plan says that the denial of authorization for this service is correct, because the enrollee has not had dual medial branch blocks.The Plan follows Medicare rules. Medicare rules state that radiofrequency medial branch neurotomy may be considered when the enrollee has had dual medial branch blocks provide 80% or greater relief of primary index pain.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 facet joint injections. Our reviewer says that the enrollee meets the Medicare criteria for the requested facet joint injections. Our physician reviewer found the records show that the enrollee had medial branch blocks on July 21, 2020 which achieved 90% relief. The enrollee satisfies the criteria for radiofrequency ablation and the requested injections are medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have been met.Therefore, we decided that the Plan has to pre-approvefacet joint injections.If the Plan does not agree with our decision,they canask 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 thecase again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACHservices.You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says a LTACH admission is not medically necessary.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 that based on the documentation provided, the health Plan's denial of LTACH coverage should be upheld.The enrollee is currently undergoing treatment at an ACH for COVID-19 and bacteremia.The enrollee was intubated/ventilated and subsequently received a tracheotomy.The enrollee remains on a ventilator. There is no evidence that the enrollee requires services that are not currently available.As LTACHs and ACHs are licensed to provide the same level of care and 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 arerequired.The enrollee can then be transferred/discharged to a lower level of care for any ongoing 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-approve LTACH services
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe clinical crown lengthening (D4249).You asked the Plan to pre-approvethe clinical crown lengthening. You say that the service is medically necessary for your condition.The Plan denied your request. The Plan says the service requested is not covered by the 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvethe clinical crown lengthening (D4249).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient surgery provided September 10, 2019.You asked the Plan to waive the copayment forthe outpatient surgery. You say that you should not be charged for this service.The Plan denied your request.The Plan says the correct cost-sharing was 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 details copayments and coinsurances in Chapter 4 of the Evidence of Coverage.You have been asked to pay a 5% coinsurance for Part B Drugs, a 20% coinsurance for surgical supplies, a $25 copayment for Outpatient surgical services, and a $10 copayment for diagnostic tests (in this case, an ECG). 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 foroutpatient surgery provided September 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient psychiatric services.You asked the Plan to pre-approvetheinpatient psychiatric services. You say that it is medically necessary to continue inpatient psychiatric hospitalization.The Plan denied your request. The Plan says the clinical information provided does not support the requested level of care. The Plan says that the enrollee can be treated in an outpatient setting.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee was admitted to the acute inpatient psychiatric hospitalization on December 14, 2020 with Major Depressive Disorder, Recurrent Severe without Psychotic Features versus Schizoaffective Disorder versus Psychosis.  Based upon review the records provided it was not expected this enrollee would improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal ideation noted and denied any auditory or visual hallucinations. The patient was compliant with treatment while not showing any acute threats to safety. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the dates in question as she did not have dangerousness to self or others but was compliant with her 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 inpatient psychiatric services have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient psychiatric services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgical services provided on June 4, 2020.
You asked the Plan to waive the copayment for the outpatient surgical services. You say that you feel you
should not be responsible for this cost share amount and you would like the Plan to reconsider your request.
The Plan denied your request. The Plan says you received outpatient surgical services on the date of service at
issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $360
copayment for surgery services provided in an outpatient hospital.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient
surgical services provided in an Outpatient hospital facility on June 4, 2020. You have been asked to pay
$287.84 for the outpatient surgical services, which is less than the contracted $360 copayment amount. The
outpatient surgical services fall within the Outpatient hospital services 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 outpatient surgical services provided on June 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefour endosteal implants.You asked the Plan to pre-approvethe endosteal implants. You say that these services are medically necessary.The Plan denied your request. The Plan says this service is not available in your benefit 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvefour endosteal implants.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve a Single-Photon Emission Computed Tomography (SPECT) test.
You asked the Plan to pre-approve SPECT test. You say that you are appealing with records. The Plan denied
your request. The Plan says that the denial of authorization for this service is correct, because this test is not
medically necessary.
The Plan follows Medicare rules. Medicare rules say that SPECT tests may be used in the evaluation of certain
conditions.
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 SPECT test. Our reviewer says that the
enrollee meets the Medicare criteria for the requested SPECT test. Our physician reviewer found the enrollee
has known history of coronary artery disease and an abnormal electrocardiogram (EKG). Given this, a SPECT
study is medically reasonable and indicated.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SPECT test have been met. Therefore, we decided that the Plan has to preapprove
a Single-Photon Emission Computed Tomography (SPECT) test.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve the Eylea. You say that you would like reconsideration because you would
like to continue with this successful treatment. The Plan denied your request. The Plan says you do not meet
step therapy exception criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Eylea. Our reviewer says that the
documentation does not support a history of previous treatment, contraindication, or intolerance to Avastin,
Mvasi or Zirabev. Our physician reviewer found step therapy criteria have not been met.
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 Eylea have not been met. Therefore, we decided that the Plan does not have
to pre-approve Eylea.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient mental health services.

You asked the Plan to pre-approve the inpatient mental health services. You say that the services are medically
necessary. The Plan denied your request. The Plan says that the enrollee's needs could be met at an outpatient
level of care.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.

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 inpatient mental health services.
Our reviewer says that coverage criteria for inpatient services have been met. Our physician reviewer found the
enrollee needed a negative PPD before transfer to another Group home, and she was having on-going visual
hallucinations. The treatment at inpatient level is appropriate.

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 inpatient mental health services have been met. Therefore, we decided that
the Plan has to pre-approve inpatient mental health services.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider for a sleep appliance.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says medically necessary is available in-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 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 a sleep appliance.