Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from August 26, 2018 through August 31, 2018.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were unaware of your benefits prior to the admission. The Plan denied your request. The Plan says the claim was processed accordingly with your 2018 EOC 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). Review of the file shows that you were admitted on August 26, 2018 and discharged on August 31, 2018. You were asked to pay a $250 copayment per day from August 26, 2018 through August 30, 2018, days 1-8 of your inpatient hospital care. You were discharged on August 26, 2018 and there was no copayment charge for the day of discharge. Per your contract there is a $250 copayment per day required for days 1-5. 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 inpatient hospital care from August 26, 2018 through August 31, 2018.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the upper denture provided on October 22, 2019.
You asked the Plan to pay for the upper denture. You say that you believe the Plan should pay the full amount for your upper denture because it was more than 10 years old. The Plan denied your request. The Plan says you are responsible for 50% coinsurance of covered services until the Plan has paid the annual benefit limit of $1,000.
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, you must pay 50% coinsurance until the Plan has paid the annual benefit limit of $1,000. The record shows that you were billed correctly by the Plan and you are responsible for 50% coinsurance for the upper denture. Therefore, we decided that the Plan does not have to pay for the upper denture provided on October 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342) for the upper left and upper right quadrants provided on June 19, 2019.
You asked the Plan to pay for the dental services. You say that you were advised by the office staff that you could get 2 cleanings per year. You say that your dentist put you on a cleaning regiment. The Plan denied your request. The Plan says periodontal scaling and root planing is not a covered service.
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, periodontal scaling and root planing is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and root planing (D4342) for the upper left and upper right quadrants provided on June 19, 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 the enrollee does not need assisted ventilation, or daily physician supervision.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 in the case of this enrollee, the most recent notes from the current acute care facility stay included evidence of a worsening infection since the partial colectomy. The white blood count is rising rapidly, and blood pressure was noted to be decreasing. This enrollee is not stable enough for discharge. Also, there are no needed services that are available at the proposed LTACH that the enrollee is not currently receiving or are already available and covered at the current setting. Therefore, this request for LTACH services will be considered not medically necessary or appropriate at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on October 28, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the
Plan requires utilization of network providers when possible and available, and requires authorization for
certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency
situation, has been documented.
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 physician's services provided on October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis
(D1110) provided on October 1, 2019.
You asked the Plan to pay for the dental services. You say that you called the Plan in January or February to
clarify your new coverage. You say that you were advised that the dollar amount was in addition to the
cleanings and exams. The Plan denied your request. The Plan says the annual maximum of $2,250 has been
exceeded.
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 annual maximum amount of $2,250
has been exceeded.
Date of Service Plan Paid
2/7/2019 $1,050
3/21/2019 $164
3/30/2019 $1036
TOTAL: $2,250
Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the
prophylaxis (D1110) provided on October 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on July 2, 2019.
You asked the Plan to pay for the dental services. You say that they took your card and there was no notification at the end that the dentist was not contracted with the plan and the services would not be covered. The Plan denied your request. The Plan says enrollee's must receive their dental services from an in-network dental provider.
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 dental services are only covered when received by a participating provider. Therefore, we decided that the Plan does not have to pay for the dental services provided on July 2, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Jardiance 10 mg tablet medication.You asked the Plan to pre-approve this medication. You say that this has been a successful therapy for the patient, and you recommend continuation of this medication regimen.The Plan denied your request. The Plan says this medication is not a covered benefit under the member's contractual policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve the Jardiance 10 mg tablet medication.Benefits for this medication 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 waive the copayment for ambulance services provided on September 9, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you went to one facility and received a computed tomography (CT) scan that found you had Diverticulitis. You state the facility told you they were unable to take care of you at that facility and you had to be transported to another hospital via ambulance. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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). Review of the file show that you received ambulance services provided on September 9, 2019. You are asked to pay a $225 copayment for the ambulance transportation. 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 ambulance services provided on September 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe vision care services provided to the enrollee on October 3, 2019 by an in-network provider.You asked the Plan to pay forthe vision care services. You say that the member should not be liable for the cost share due to not being aware the insurance was being billed for services.The Plandenied your request. The Plan says the services were not routine.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 vision care services have not been met. The enrollee does have coverage for supplementalvision benefits including one routine vision exam every year (including eye refraction for eyeglasses/contact lenses). However, the enrollee received a non-routine eye exam on date of service October 3, 2019, and according to the 2019 EOC, page 100, thereis a $35 copayment for each specialist visit for Medicare-covered services. The enrollee is asked to pay a $35 copayment for the specialist office services and $25 for the eye refraction.Therefore, we decided that the Plan does not have to pay forthe vision care services provided to the enrollee on October 3, 2019 by an in-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bronchial thermoplasty.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered, per the NCD.
The Plan must follow Medicare rules. Medicare rules say that bronchial thermoplasty is not covered for any pulmonary condition. This cannot be covered for your pulmonary condition. 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 pre-approve bronchial thermoplasty.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Lispro insulin provided on September 20, 2019.
You asked the Plan to pay for the Lispro insulin. You say that this insulin wasn't self-administered. The Plan denied your request. The Plan says that this isn't covered under Part B.
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 pay for the Lispro insulin provided on September 20, 2019.
Benefits for the Lispro insulin 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
You asked the Plan to pre-approve a portable oxygen concentrator. You say that the requested item is
necessary. The Plan denied your request. The Plan says you currently have portable oxygen tanks that are
working appropriately, therefore coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered
reasonable and necessary.
The file shows that you have a stationary concentrator and portable size B oxygen tanks. A stationary
concentrator and portable size B oxygen tanks serve the same purpose as a portable oxygen concentrator.
Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator (E1392).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Magnetic Resonance Imaging (MRI) of the
Lumbar Spine (72148) provided June 21, 2019.
You asked the Plan to waive the copayment for the MRI. You say that the copayment should only be $20. The
Plan denied your request. The Plan says the correct copayment 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 $225
copayment for Outpatient Hospital Services.
You have been asked to pay a $165.11 copayment for the MRI. Because it was provided in the outpatient
hospital setting, the MRI falls within the Outpatient Hospital Services benefit category. The Medicare
allowable amount of $165.11 is less than the $225 copayment stipulated in the plan contract. 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 Magnetic Resonance Imaging (MRI) of the Lumbar Spine (72148)
provided June 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214 and a complete maxillary denture (D5110).
You asked the Plan to pre-approve the dentures. You say that you lost your dentures in a house fire. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also says the frequency limit has been exceeded.
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 and dentures are a covered service, the frequency limit has been reached. The record shows that the Plan previously paid for dentures that you received on August 28, 2015. Therefore, we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214 and a complete maxillary denture (D5110).
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 member was admitted for acute care on 02/10/2020 with dysuria, hematuria, and a rash. She was treated for an E. coli urinary tract infection, hypertension, acute kidney injury, morbilliform rash, anemia, and elevated brain natriuretic peptide (BNP). Her relevant past medical history includes congestive heart failure, hypertension, and a tracheostomy since 2017. She also has super morbid obesity with a body mass index of 62. The member had previously been able to ambulate at a modified independent level. As of 02/19/2020 she was able to transfer with supervision. She was able to tolerate standing for 5 minutes with a rolling walker. Her blood pressure was still slightly elevated. Medications were being continued for her hypertension. Her rash was improving with steroid lotion. The member is status-post treatment for urinary tract infection as described above. The member's medical conditions appear stable. There are no complex wound care needs. She does not require medical oversight of her condition at an acute hospital level of care. The member requires physical therapy for mobility and endurance. There is no clear need for occupational therapy. There is no new identified significant impairing upper extremity condition. The member's debility can be appropriately treated by progressing her mobility with the physical therapy treatments being provided. The member is limited by the severity of her comorbid medical conditions. She would not be expected to be able to fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy
program would significantly impact the member's condition differently compared with therapy provided at a less intense level. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are needed. 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 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 care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found there are no noted daily skilled complex
nursing needs. The records do not support the need for daily skilled therapy in an SNF.
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 care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRF admission and services for the enrollee.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says there are no skilled nursing or therapy needs that require the requested level of care.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 physician reviewer found that the enrollee is medically stable with no evidence of need for supervision by rehab physician, or needs acute rehab nursing care. She may benefit from further speech, physical and occupational therapy, but does not require an intensive therapy program. Therefore, an IRF admission is not medically necessary based on her current functional status and medical stability.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicarerules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on
December 30, 2018.
You asked the Plan to waive the copayment for the ambulance transport. You say that you did not want to take
the ambulance. The Plan denied your request. The Plan says that the claim processed 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 $250
copayment for Medicare-covered ambulance services.
You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls
within the Medicare-covered ambulance 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 ambulance transport provided on December 30, 2018.