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

We decided that the Plan does not have to pay for the medical services provided on November 27, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the immunization services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says precertification/authorization is absent.
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. 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 November 27, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the CPAP device provided from January 12,
2020 to March 12, 2020.
You asked the Plan to waive the cost share for the CPAP device. You say that you were not using the machine
and did not know that the CPAP machine was a rental. 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. Your
contract with the Plan says that there is a $110 deductible that applies towards CPAP devices and 15%
coinsurance for in-network Medicare-covered benefit.
The CPAP device you asked the Plan to waive the cost share for falls within the "Durable Medical Equipment
(DME) and Related Supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in
the contract that there is a $110 deductible that applies towards CPAP devices and 15% coinsurance for innetwork
Medicare-covered benefit. See chart below.
Date of Service Service Allowed Amount Deductible/Coinsurance Member
Liability
January 12, 2020 CPAP device $46.14 $110 $46.14
February 12, 2020 CPAP device $46.14 $110 $46.14 - This is
where you met
your deductible
amount.
March 12, 2020 CPAP device $46.14 15% $6.92
Total $99.20
This cost sharing is a contractual obligation that had not been met at the time the CPAP device was received on
January 12, 2020 to March 12, 2020. Therefore, we decided that the Plan does not have to waive the cost share
for the CPAP device provided from January 12, 2020 to March 12, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from December
31, 2019 through January 3, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you have never received a bill
from the hospital before. You say that it has always been fully covered. 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 $395
copayment each day for days 1 to 4 for in-network, Medicare-covered hospital care.
You have been asked to pay a $1,185 copayment for the inpatient stay. ($395/day x 3 days = $1,185). The
inpatient stay falls within the "Inpatient Hospital Care" 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 inpatient stay provided from December 31, 2019 through January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on February 12, 2020.You asked the Plan to pay for the subsequent nursing facility care.The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 21, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the outpatient services. You say that you would like reconsideration based on the
records submitted. The Plan denied your request. The Plan says a Medicare HMO and services should be
received from network providers who are listed in the provider directory, except when urgent or an emergency.
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 November 21,
2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on October 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an eye exam. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an eye exam provided on October 23, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fordialysis services provided on January 2, 2020 through February 28, 2020.You asked the Plan to waive the copayment forthe dialysis services. You say that you would like reconsideration because the cost of these services creates a financial hardship.The Plan denied your request. The Plan says per your EOC, the 20% coinsurance for dialysis services applies.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such ascopayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Services to treat kidney disease. You have been asked to pay $55.12 for each dialysis service. The allowed amount for these services is $275.60. 20% of $275.60 is $55.12. You have been asked to pay the correct amount for each of these services.You have been asked to pay a 20% coinsurance for the dialysis services. The dialysis services fall within the Services to treat kidney disease 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 Plandoes not have to waive the copayment fordialysis services provided on January 2, 2020 through February 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab tests provided on November 20, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for lab tests. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that
the member's primary care physician did not refer 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 lab tests provided on November 20, 2019 by an
out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical assistant services on an arthroscopy (29827, 29826) provided on October 2, 2019.You asked the Plan to pay for surgical assistant services. You say that this provider was requested by the surgeon.The Plan denied your request. The Plan says this provider is not eligible for payment for surgical assistant services.The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners.Therefore, we decided that the Plan does not have to pay for surgical assistant services on an arthroscopy (29827, 29826) provided on October 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says that based on Medicare guidelines, the enrollee does not meet the requirements for approval of LTACH services.
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 short-term acute care hospital can provide for all the enrollee's present inpatient care needs and the enrollee is receiving an appropriate level of care in the present setting. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled nursing facility. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on January 9, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for an office visit. You say that you were unaware that this provider was out-of-network.
The Plan denied your request. The Plan says prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an office visit provided on January 9, 2020 by an
out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 18, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the drug testing rendered on September 18, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility(SNF) services.You asked the Plan to pre-approveSNF services. You say that SNF services are medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria are not met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records do not show that you 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. The records do not show that you requireadditional skilled therapy to safely and effectively provide medically necessary and reasonable treatment. Skilled nursing and therapy services are not medically reasonable and necessary (or a combination of these services) on a "daily basis". The records show you are generally medically stable. Your medical status was deemed stable enough to discharge from an acute IRF setting. You do 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray provided on November 29,
2019.
You asked the Plan to waive the copayment for the chest x-ray. You say that the x-ray was part of the follow up
appointment. You say that if the x-ray is done as part of the appointment you would not owe the x-ray
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 $40
copayment for each Medicare-covered standard x-ray and ultrasound.
You have been asked to pay a $40 copayment for the chest x-ray. The chest x-ray falls within the "Outpatient
diagnostic tests and therapeutic services and supplies" benefit category. There is no provision in the contract
which indicates an x-ray copayment would be waived if performed during a follow-up appointment. 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 chest x-ray provided on November 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a gel pressure mattress pad (E0185).You asked the Plan to pre-approve a gel pressure mattress pad. You say that you are in a lot of pain and needs a bed pad to help with your pain.The Plan denied your request. The Plan says the mattress overlay does not meet the Medicare criteria.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 a gel pressure mattress pad. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that there is no documentation of complete immobility (notes state aquatherapy helps pain), an inability to make changes in body position significant enough to alleviate pressure or the presence of a pressure ulcer on the trunk or pelvis. In addition, there is no mention of impaired nutritional status, fecal or urinary incontinence, altered sensory perception or compromised circulatory status accompanying any of these conditions. The review indicates that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a gel pressure mattress pad have not been met.Therefore, we decided that the Plan does not have to pre-approve a gel pressure mattress pad (E0185).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit and physician services provided on March 4, 2020 by an out of network (OON) provider.You asked the Plan to pay foran office visit and physician services. You say that coverage should be considered because you suffered an injury to your foot while out of state, and due to your diabetes, you're at risk for infection and complications from foot injuries.The Plan denied your request. The Plan says prior authorization was not 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 foran office visit and physician services provided on March 4, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for CT scan provided on February 12, 2020.You asked the Plan to waive the copayment forthe CT scan. You say that you were not aware there was a copayment for imaging services when you signed up for the plan. You say you should not be responsible for the copayment. 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 $195 copayment for Medicare-covered diagnostic radiology including all other diagnostic and nuclear medical radiological services. You have been asked to pay a $195 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeuticservices 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 forthe CT scan provided on February 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your
request. The Plan says that the information submitted doesn't meet the Plan's medical necessity guidelines for
coverage.
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 Prolia. Our reviewer says that Prolia is
not medically reasonable and necessary in this case. You reportedly have osteoporosis without fracture. A
request has been made for Prolia to treat the osteoporosis. The health plan requires that zoledronic acid be used
first. There is no evidence that you are allergic to or intolerant of zoledronic acid. There is no evidence that you
have tried and not responded to zoledronic acid. There is no documentation as to why zoledronic acid would
not be expected to be safe and effective for you. Our physician reviewer found that your condition does not
meet step therapy criteria for Prolia.
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 not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.