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

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says there are two skilled nursing facilities that have accepted the enrollee and can provide the care.
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 LTACH. The enrollee appears to have completed a course of long-term antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires ongoing long-term acute services. Ongoing care at a LTACH is not shown to be medically necessary or reasonable. 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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the next generation sequencing (NGS) rendered on September 14, 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 the testing is not covered.The Plan must follow Medicare rules. Medicare rules say that NGS is covered when specific criteria are met. We looked at the file and Medicare rules. The file shows that the enrollee does not have either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. The testing was performed to determine medication choices.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 next generation sequencing (NGS) rendered on September 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 12.
You asked the Plan to pre-approve the dental service. You say that you need the crown for tooth # 12. The Plan denied your request. The Plan says the documentation provided does not support the necessity for a crown for tooth # 12.
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 requested dental service is not medically necessary. Our physician reviewer found the provided documentation shows minimal loss of tooth structure that would indicate a need for full coverage. The reviewer found that along with the lack of requested supplemental information, there is no showing of the necessity for the requested crown. 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 not been met. Therefore, we decided that the Plan does not have to pre-approve a crown (D2750) for tooth # 12.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the declotting procedure and alteplase
recombinant injection provided on February 12, 2020.
You asked the Plan to waive the cost share for the declotting procedure and alteplase recombinant injection.
You say that you are normally charged $10 or less for the test. You say that you shouldn't have to pay the cost
billed for the procedure. The Plan denied your request. The Plan says the cost share 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 $300
copayment for outpatient surgery services and 20% of the cost for Part B covered chemotherapy drugs and
other Part B covered drugs.
You have been asked to pay a total of $322.80 for the declotting procedure and alteplase recombinant injection.
Service Allowed Amount Standard Cost Share Member Liability
Declotting Procedure $287.66 $300 $287.66
Alteplase Recombinant
Injection
$175.70 20% $35.14
TOTAL: $322.80 The declotting procedure falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The alteplase recombinant injection falls within the "Medicare Part B prescription drugs" 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 cost share for the declotting procedure and alteplase recombinant injection provided on February 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on December 2, 2019 by an out of network (OON) provider.You asked the Plan to pay for nurse practitioner services. 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 the custodial facility is also out-of-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 for nurse practitioner services provided on December 2, 2019 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on December 23, 2019.
You asked the Plan to waive the copayment for an EGD. You say that you received services in an outpatient surgery center and disagree with the 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 $325 copayment for outpatient surgery services provided in an outpatient hospital facility. The record shows that you received an EGD on December 23, 2019 at an outpatient hospital facility. Therefore, you are responsible to pay the $325 copayment. You have been asked to pay a $325 copayment for an EGD. An EGD falls within the outpatient surgery, including 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 an EGD provided on December 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite provided on October 23, 2019.
You asked the Plan to pay for the resin-based composite. You say that prior to the procedure, you confirmed with the provider that it would be covered under your Plan. You also say that you were told that it would be covered and was a procedure that would be integral to your preventive and prescriptive health care. The Plan denied your request. The Plan says this service is not covered under your contract under any normal circumstances.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the resin-based composite provided on October 23, 2019.
Appeal type: Hospice
Decision: Favorable

We decided that the Plan has to pay forthe laboratory services provided on September 25, 2019.You asked the Plan to pay forthe laboratory services. You say that the services were medically necessary. You also say that the claim cannot be denied for prior authorization.The Plan denied your request. The Plan says that Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan did not provide a copy of the enrollee's applicable hospice election information. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case. Thus, the Plan has not substantiated their denial of payment in this case.Therefore, we decided that the Plan has to pay forthe laboratory services provided on September 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit for a new patient (99201) provided on August 30, 2019.
You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a new patient procedure code cannot be billed multiple times within three years.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99201 is office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
We find that CPT code 99201 is not supported in the record. Specifically, the record indicates that the same provider billed CPT code 99201 for this enrollee on December 27, 2018. Per Medicare, a new patient has not received professional services from the physician or group within three years. This is within the three-year time frame and is therefore an inappropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit for a new patient (99201) provided on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network cardiologist.
You asked the Plan to pre-approve these services. You say that your neighbor was stabilized by this provider's
care. The Plan denied your request. The Plan says the services are available from network providers.
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 cardiologist.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ostomy pouch provided on January 19, 2020. You asked the Plan to waive the coinsurance for the ostomy pouch. You say that you have never had to pay a copayment before. 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 20% coinsurance for prosthetic devices and medical supplies. You have been asked to pay $12.92 which is 20% of the allowed amount for the ostomy pouch. The allowed amount is $64.60. ($64.60 x 20% = $12.92). The ostomy pouch falls within the "Prosthetic devices 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 for the ostomy pouch provided on January 19, 2020. Our decision is only about the 2020 service. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for out of network physician services provided on February 8, 2020.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
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 provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 out of network physician services provided to the enrollee on February 8, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided from January 8, 2020 through January 16, 2020.
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that you were never discharged. You say that this was all part of one hospital stay. 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 $300 copayment per admission for each medically necessary inpatient stay. If you are discharged from one level of care and readmitted to another level of care, separate copayments will apply. You have been asked to pay a $300 copayment for the inpatient rehabilitation stay. The inpatient rehabilitation stay falls within the "Inpatient hospital care" benefit category. A transfer to a different level of care is considered a new admission. 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 rehabilitation stay provided from January 8, 2020 through January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician's services provided on October 22, 2019.
You asked the Plan to pay for the physician's services. 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 physician's services provided on October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nurse practitioner services provided on December 31, 2019.
You asked the Plan to pay for the nurse practitioner services. 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 nurse practitioner services provided on December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for Dental services (D6080, D0220, D0230, D6090) provided October 15, 2019.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says The implant repairs (D6080, D6090) are not covered benefits. The radiographs (D0220 and D0230) are only covered when provided in-network.
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. Implant repairs are not a covered service, and the remainder of the services at issue are only covered when provided in-network. Therefore, we decided that the Plan does not have to pay for Dental services (D6080, D0220, D0230, D6090) provided October 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for Computed Tomography Angiography (CTA) of the chest (71275) provided January 8, 2020.
You asked the Plan to waive the copayment for the CTA. You say that you had another CTA the day before and the copayment should be waived because they should have done both services on the same day. 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 says that you must pay a $150 copayment per day for Diagnostic Imaging. You have been asked to pay a $150 copayment per day for the CTA. The CTA falls within the Diagnostic Imaging 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 Computed Tomography Angiography (CTA) of the chest (71275) provided January 8, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide additional routine transportation trips. You asked the Plan to provide additional routine transportation trips. You say that you have more appointments to get to. The Plan denied your request. The Plan says you have 2 trips remaining currently for the 2020 calendar year. Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 one-way trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have almost exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foracupuncture services provided September 20, 2019 to December 27, 2019.You asked the Plan to pay foracupuncture. You say that these services should be covered by the Plan.The Plan denied your request. The Plan says the Plan contract is clear that acupuncture is not covered under any circumstances.The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.The services at issue in this appeal are acupuncture services.Therefore, we decided that the Plan does not have to pay foracupuncture services provided September 20, 2019 to December 27, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveI brance Cap 125mg.You asked the Plan to pre-approveI brance Cap 125mg. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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 Ibrance Cap 125mg.Benefits for Ibrance Cap 125mgmaybe available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.