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

We decided that the Plan does not have to pre-approve additional routine transportation mileage.
You asked the Plan to pre-approve the additional mileage. You say that you need to see the cardiologist as soon
as possible. The Plan denied your request. The Plan says trips cannot exceed 50 miles one-way driving
distance.
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 routine transportation up to 50 miles one-way.
We looked at your request, the records in the case file, and the rules. The requested trip is 188 miles total
distance. Based on this information, we decided that the Plan's rules for coverage of routine transportation have
not been met. Therefore, we decided that the Plan does not have to pre-approve additional routine
transportation mileage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent observation care (99226) provided on June 5, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for subsequent observation care. You say that the received treatment was medical necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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 had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 subsequent observation care (99226) provided on June 5, 2021, 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 and physician services provided on March 16, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for an office visit and physician services. You say that you would like this claim reprocessed and paid. 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 had network providers available who could have provided 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 and physician services provided on March 16, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the radiofrequency Ablation (RFA) (64635, 64636).
You asked the Plan to pre-approve the RFA. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that an initial thermal RFA of cervical, thoracic, or lumbar paravertebral facet joint (medial branch)nerves is considered medically reasonable and necessary for patients who have had at least two (2) medically reasonable and necessary diagnostic MBBs, with each one providing a consistent minimum of 80% sustained relief of primary (index) pain (with the duration of relief being consistent with the agent used). 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 RFA. Our reviewer says that the service is not medically necessary. Our physician reviewer found your records show you did not have two (2) facet joint injections. 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 RFA have not been met. Specifically, you did not have two (2) facet joint injections. This means the service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the radiofrequency Ablation (RFA) (64635, 64636).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the vitamin B-12 injections you received on April 16, 2021.
You asked the Plan to waive the coinsurance for the vitamin B-12 injections. You say that you think you are being overcharged for this because you only received two injections. The Plan denied your request. The Plan says you were charged this coinsurance correctly. You were charged coinsurance for the drug itself and the two injections of it, so this amount is correct.
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 Medicare Part B drugs. You have been asked to pay 20% coinsurance for the vitamin B-12 injections. The vitamin B-12 injections fall within the Medicare Part B 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 coinsurance for the vitamin B-12 injections you received on April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two gingival irrigations (D4921 x2), surgical placement of implant body: endosteal implant (D6010), two custom fabricated abutments (D6057 x2), and two abutment supported porcelain fused to metal crowns (D6059 x2).
You asked the Plan to pre-approve the gingival irrigations, endosteal implant, custom fabricated abutments, and abutment supported porcelain fused to metal crowns. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two gingival irrigations (D4921 x2), surgical placement of implant body: endosteal implant (D6010), two custom fabricated abutments (D6057 x2), and two abutment supported porcelain fused to metal crowns (D6059 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve orthopedic footwear.
You asked the Plan to pre-approve foot orthotics. You say that this is medically necessary. The Plan denied
your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.
Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your
condition. Therefore, we decided that the Plan does not have to pre-approve orthopedic footwear.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Epicord (Q4187).

You asked the Plan to pre-approve the Epicord. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that a Failed Response is defined as an ulcer or skin deficit that has failed to respond to documented appropriate wound-care measures, has increased in size or depth, or has not changed in baseline size or depth and has no indication that improvement is likely (such as granulation, epithelialization or progress towards closing). 

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 Epicord. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee's wound has gradually improved with standard treatment over the past many weeks. Based on the records showing no failure of standard treatment, there is insufficient justification for grafting 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 Epicord have not been met. Specifically, the enrollee wound has been improving. This means the service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the Epicord (Q4187).
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee can safely receive the services he needs in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for sepsis, pneumonia, and gallstones. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. 

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 for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency department visit provided on April 3, 2021.

You asked the Plan to waive the copayment for an emergency department visit. You say that you should not have to pay this claim and it should be paid in full. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $90 copayment for emergency care. Your contract with the Plan also clearly says that if you are immediately admitted to the hospital form the Emergency Department, then the $90 copayment is waived.

You have been asked to pay a $90 copayment for an emergency department visit. The records show that you went to the emergency room and were not admitted into the hospital but placed in observation while tests were conducted. The EOC confirms that $90 is the required copayment for this service. 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 emergency department visit provided on April 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the biologic materials to aid in soft and osseous tissue regeneration (D4265).
You asked the Plan to pre-approve the biologic materials to aid in soft and osseous tissue regeneration (D4265). You say that you want to file an appeal for the denied authorization. The Plan denied your request. The Plan says the service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the biologic materials to aid in soft and osseous tissue regeneration (D4265).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two bone replacement grafts for the first site in the quadrant (D4263 x2), three bone replacement grafts for each additional site in the quadrant (D4264), and four guided tissue regenerations (D4266 x4).
You asked the Plan to pre-approve the bone replacement grafts and guided tissue regenerations. You say that the bone implantation is necessary due to the movement of one of the molars and to avoid tooth loss. The Plan denied your request. The Plan says these services are not covered.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve two bone replacement grafts for the first site in the quadrant (D4263 x2), three bone replacement grafts for each additional site in the quadrant (D4264), and four guided tissue regenerations (D4266 x4).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray you had on April 9, 2021 at
an outpatient hospital facility.
You asked the Plan to waive the copayment for the chest x-ray. You say that these services were done by a
radiology clinic, not at a hospital. The Plan denied your request. The Plan says you were charged this
copayment correctly. The Plan says that because the allowed amount for this service ($78.27) is less than your
copayment obligation, you are responsible for the full allowed amount. The Plan says that the provider that
performed this service bills as an outpatient hospital facility.
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 $100
copayment for basic radiological services at an outpatient hospital.
You have been asked to pay a $100 copayment for the chest x-ray. The chest x-ray falls within the basic
radiological services at an outpatient hospital 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 chest x-ray you had on April 9, 2021 at an outpatient hospital facility.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services and equipment provided to the enrollee on February 22, 2021.
You asked the Plan to pay for this claim. You say that this claim should be paid. The Plan denied your request. The Plan says due to the enrollee's hospice status at the time of service, this claim must be reviewed by Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for medical services and equipment provided to the enrollee on February 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on March 23, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you didn't want to go to the hospital but your facility insisted. You stated that you cannot pay this bill. The Plan denied your request. The Plan says you were charged this copayment 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 $260 copayment for ambulance services. You have been asked to pay a $260 copayment for the ambulance services. This copayment applies regardless of the reason for the transport. 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 you received on March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on February 4, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's 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 had network providers available who could have provided 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 physician services provided on February 4, 2021 by an out-of-network (OON) provider.
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 LTACH care is medically necessary for
the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have 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 that the patient is a 62-year-old male who was admitted to the current acute care
hospital with acute on chronic left foot osteomyelitis treated with antibiotics, respiratory care, and therapy. The
notes state that the patient is unlikely to result in a cure or limb salvage with treatment. The patient appears to
be currently stable, requiring only short-term additional acute care services which can be safely completed at
the current facility for his chronic condition.
The patient does not require services at the LTACH that are not already available at the current facility. In
addition, there are no services at the LTACH that the patient requires that are not already available and covered
at the current facility. Therefore, this request for LTACH services will be considered not medically necessary
as transfer at this time would not provide a clinical advantage. Transfer to a lower level of care may be
considered soon when treatment has completed.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation, comprehensive oral evaluation and prophylaxis provided on November 9, 2020.
You asked the Plan to pay for the limited oral evaluation, comprehensive oral evaluation and prophylaxis. You say that you were under the impression that 2 cleanings per year and x-rays were covered. You say that you cannot afford the $300 bill. The Plan denied your request. The Plan says you have maxed out the allowable benefit for the year.
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 also have a maximum benefit of $2,000 a year for your covered dental services. The Plan paid $2,000 toward the dental services received on June 24, 2020 and October 2, 2020, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation, comprehensive oral evaluation and prophylaxis provided on November 9, 2020.