Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the enrollee has severe dementia and currently resides in a memory care facility. You say that on the date of service the enrollee fell and 911 was called due to the facility's operating policy. You stated that you arrived at the same time as the emergency responders and were able to communicate with the enrollee that she was not hurt. You decided to decline transportation of the enrollee to the hospital as it is very stressful for the enrollee to go to the hospital and also very expensive. You say that you were surprised that the Plan denied the paramedic charge since it would have been covered by the Plan at a higher cost if she had been transported.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 October 6, 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 forthe ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forDME provided on November 22, 2019 and December 22, 2019.You asked the Plan to waive the coinsurance forDME. You say that you were not informed that you would owe a copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 20% coinsurance for DME and related supplies. You received DME on November 22, 2019. The allowed amount is $2,899.50 and 20% of that is $579.90. You received DME on December22, 2019. The allowed amount is $2,899.50 and 20%of that is $579.90.Thetotal amount you owe is: $1,159.80.You have been asked to pay the total coinsuranceamount of $1,159.80for DME. DME falls within the DME and related 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 coinsurance forDME provided on November 22, 2019 and December 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor for enrollee.You asked the Plan to pre-approve the requested device. The Plan denied your request. The Plan says the enrollee is no longer on insulin and only checks blood sugars 1-2 times daily.The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors area only covered under certain medical indications. 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 requested device. Our physician reviewer found that the enrollee does not check blood sugar levels the required 4x a day. It is unclear why monitoring his blood sugar levels with a glucometer 1x a day would be insufficient for this enrollee who is on medication for diabetes that do not cause low blood sugar levels.Therefore, the requested device is not considered medically reasonable and 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 the requested device have not been met.Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor for 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-approve the 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 fever and advanced rheumatoid arthritis. The enrollee is not intubated/ventilated. 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, 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-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of sphincter augmentation device (LINX procedure).
You asked the Plan to pre-approve LINX procedure. You say that you are fully in support of the LINX procedure for the enrollee. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the LINX procedure is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that the LINX procedure is considered not medically reasonable and necessary and is not covered by Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of LINX procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of sphincter augmentation device (LINX procedure).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78816).You asked the Plan to pre-approve the PET scan. You say that the PET scan is medically necessary.The Plan denied your request. The Plan says coverage criteria has not been met.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case fileand apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the PET scan. Our reviewer says that the PET scan is not indicated in this case. Our physician reviewer found there is no evidence in the provided records that the patient has a specific solid tumor that is biopsy proven or strongly suspected based on other diagnostic testing. This is required for coverage under Medicare rules.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 PET scan have not been met.Therefore, we decided that the Plan does not have to pre-approve a Positron Emission Tomography (PET) scan (78816).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Uloric tablets for the enrollee.
You asked the Plan to pre-approve the tablets. You say that this is medically necessary. The Plan denied your request. The Plan says these are usually intended for patient self-administration.
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 Uloric tablets for the enrollee.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown (D2740) for tooth # 19.
You asked the Plan to pre-approve the dental service. The Plan denied your request. The Plan says that the tooth does not have significant breakdown due to decay or trauma. The Plan also says that the crown is not medically necessary.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental service when the services are medically necessary and reasonable. 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 dental service. Our reviewer says that the service is medically necessary. Our physician reviewer found there is a large restoration and possible crack indicated in the radiographs and photographs that were provided. The reviewer found that that the crown for tooth # 19 is medically reasonable and necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental service have been met. Therefore, we decided that the Plan has to pre-approve a crown (D2740) for tooth # 19.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit provided on November 26, 2019 by an out of network (OON) provider.You asked the Plan to pay foran office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says these services could have been provided 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 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 provided on November 26, 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 office visit provided on October 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services could have been provided by a primary care physician.
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 October 24, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF).You asked the Plan to pre-approveadmission to a skilled nursing facility (SNF). You say that the requested admission to a SNF is medically necessary.The Plan denied your request. The Plan says the requested admission to a SNF does not meet criteria.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 admission to a skilled nursing facility (SNF). Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee was admitted and found to have cholecystitis status post laparoscopic cholecystectomy 3/30/2020. The enrollee is now generally weak, but hemodynamics are stable (mild elevations in blood pressure is noted) and the enrollee is on room air, saturating oxygen well. He is debilitated, but tolerating advancement in diet. Co-morbid conditions include dementia. Functionally, the enrollee is mostly supervision for mobility and transfers. The enrollee is now mostly supervised for all care. The enrollee has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care. The enrollee's vital signs are stable; the enrollee is tolerating an oral diet; and ongoing SNF is thereby not supported. SNF is not medically necessary.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an x-ray to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an x-ray. You say that the member needs sitz mark study test. The Plan denied your request. The Plan says there are in-network providers available 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 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. Please contact the Plan for a list of in-network providers available for these services. 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 an x-ray to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe amalgam fillings (D2140) provided on October 31, 2019.You asked the Plan to reimburse you forthe dental services. You say that your insurance card says that you have dental coverage. You say thatThe Plan denied your request. The Plan says amalgam fillings are not listed as 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, amalgam fillings are not among those covered under this benefit.Therefore, we decided that the Plan does not have to reimburse you forthe amalgam fillings (D2140) provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on December 17, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you disagree with the charges because the provider was rude. The Plan denied your request. The Plan says the claims were processed correctly, and you are being charged the correct 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 $35 copayment for each specialist visit. You have been asked to pay a $35 copayment for a specialist visit. A specialist 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 a specialist visit provided on December 17, 2019.
We note your complaint that the provider was rude. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve a tier exception for Tobramycin (J7682).You asked the Planto pre-approvethe tier exception. You say that this is medically necessary.The Plandenied your request. The Plansaystier exceptions only apply to Part D drugs.The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs.The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea tier exception for Tobramycin (J7682).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdominal aortic aneurysm screening provided on December 6, 2019.You asked the Plan to pay for the abdominal aortic aneurysm screening. You say that you would like reconsideration because the doctor found evidence of afib and would like to confirm the diagnosis before taking any steps forward. The Plan denied your request. The Plan says you have already received this service so this benefit has been exhausted.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The Health Plan contract clearly states that abdominal aortic aneurysm screening is a one-time benefit.We looked at your request, the file and the rules. Based on this information we decided that criteria for coverage of the abdominal aortic aneurysm screening have not been met.  Specifically, the record indicates you already had this screening and it was paid by the Plan. The benefit for this service has been exhausted. Therefore, we decided that the Plan does not have to pay for an abdominal aortic aneurysm screening provided on December 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the radiation therapy provided from October 11, 2019 to December 9, 2019.
You asked the Plan to waive the copayments for the radiation therapy. You say that you were never told each treatment would be $60. You say you thought the radiation was covered and were never told the cost would be this much. 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 $60 copayment for radiation therapy performed at a freestanding radiological facility or physician's office. You have been asked to pay a $60 copayment for the radiation therapy on each date of service. The radiation therapy 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 copayments for the radiation therapy provided from October 11, 2019 to December 9, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve massage therapy.
You asked the Plan to pre-approve these services. You say that the services have been helping your pain. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pre-approve massage therapy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin, Paclitaxel and Pembrolizumab with supporting medications for the enrollee.
You asked the Plan to pre-approve the drugs. You say that this is medically necessary. The Plan denied your request. The Plan says this drug regimen is not supported in the medical literature for metastatic oropharynx cancer.
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 the drugs. Our reviewer says that the requested drugs are not medically reasonable or necessary. Our physician reviewer found the enrollee has recurrent/metastatic squamous cell carcinoma of presumably hand and neck origin, and has only received prior localized therapy with cisplatin and radiation. However, for metastatic disease pembrolizumab is used in combination with cisplatin or carboplatin plus fluroruracil and not paclitaxel. The service is not reasonable or medically 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 the drugs have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Paclitaxel and Pembrolizumab with supporting medications for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a follow-up visit provided by a specialist on December 12, 2019.
You asked the Plan to waive the copayment for a follow-up visit. You say that follow-up visits should not be subject to cost-sharing charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $35 copayment for each specialist visit. You received a follow-up visit on December 12, 2019. Follow-up visits are subject to cost-sharing charges. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for a follow-up visit. A follow-up 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 a follow-up visit provided by a specialist on December 12, 2019.