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

We decided that the Plan does not have to waive the coinsurance for the facility fee or the skin cancer surgery provided on May 14, 2019.
You asked the Plan to waive the coinsurance for the facility fee and the skin cancer surgery. You say that you are being overcharged. 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 40% coinsurance for out-of-network Medicare-covered outpatient surgery and 40% coinsurance for out-of-network physician specialist services (including surgery second opinion and telehealth or urgently needed services). You have been asked to pay a total of $1,481.87 for the facility fee and the skin cancer surgery. The facility fee falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The skin cancer surgery falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. See chart below.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran MRI provided on September 24, 2019.You asked thePlan to waive the copayment foran MRI. You say that if you had known how much this would cost you would have cancelled this visit.The Plan denied your request. The Plan says the correct copayment has been 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 for outpatient diagnostic tests/in-network/diagnostic radiology. You have been asked to pay a $150 copayment for an MRI. An MRI falls within the outpatient diagnostic tests/in-network/diagnostic radiology benefit category. This means that you have been asked to pay the correctamount 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 foran MRI provided on September 24, 2019.
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 enrollee was admitted to acute care on 1/14/20 and is now status post elective decompressive laminectomy L4-5, L5-S1. Now, the enrollee is being managed for pain in the post-operative setting. There are no signs of fever or toxicity, and the H&H is stable. Nephrology was consulted for hyponatremia, but Na+ levels are now stable. Overall, minimal assist is needed for mobility and activities of daily living. Spinal precautions are in place. Records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a lower level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a lower level of care. In this case, the enrollee is mostly minimal assist for functional transfers and activities of daily living and a less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period. 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe retrograde filling and apicoectomy provided on September 10, 2019.You asked the Plan to pay forthe retrograde filling and apicoectomy. You say that a notice of non-coverage was not given to you.The Plan denied your request. The Plan says these services are not a covered benefit under Medicare or your plan.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 forthe retrograde filling and apicoectomy provided on September 10, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the enrollee is unfit to go home, and needs strengthening on a daily basis.The Plan denied your request. The Plan says that the enrollee dos not require daily skilled nursing orrehab services.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 physician reviewer found that the enrollee continues to receivewound care. He has pain which needs to be assessed and treated. Herequires oversight of his medical conditions and medication management. He is at risk for secondary complications of immobility such as further pressure ulcers and contractures. The enrollee has not returned to his prior level of function. He requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. Herequires both daily skilled therapy and nursing services.He is unable to perform essential activities of daily living such as bed mobility without assistance and already has a sacral pressure ulcer.The enrollee'scondition would be expected to deteriorate with services provided on a less than daily basis. Hehad previously been able to function independently prior to his original hospitalization. He is participating in the therapy treatments being provided and is improving. There is a reasonable expectation of a reduction in burden of care with a goal of a successful return to the community through the SNF level care being requested.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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Plan has to pre-approveskilled nursing facility (SNF) care.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 1/3/20 from outside hospital for neurological evaluation of right intraparenchymal hemorrhage. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. All medically necessary care is being provided in the current acute care setting. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The health plan has approved ongoing care in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira (J0135).
You asked the Plan to pre-approve Humira. You say that the patient needs this medication. The Plan denied
your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D
prescription drug plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Humira (J0135).
Benefits for Humira 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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve13 physical therapy (PT) visits and 5 occupational therapy (OT) visits.You asked the Plan to pre-approve13 PT visits and 5 OT visits. You say that the services are medically necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.We asked our physicianreviewer 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 13 PT visits and 5 OT visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the provided medical records do not indicate that continued physical therapy and occupational therapy visits are medically reasonable and necessary. The enrollee appears to be back to her baseline level of function.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 13 PT visits and 5 OT visits have not been met.Therefore, we decided that the Plan does not have to pre-approve13 physicaltherapy (PT) visits and 5 occupational therapy (OT) visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Jardiance.
You asked the Plan to pre-approve Jardiance. The Plan denied your request. The Plan says medications are not covered by the plan benefits.
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 Jardiance
Benefits for Jardiance 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on September 30, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says nonemergent,
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
service 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 September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation system.You asked the Plan to pre-approvethe power seat feature. The Plan denied your request. The Plan says the service is not primarily medical in nature.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  We looked at the file and the Medicare rules. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approvea power seat elevation system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse the full amount forthe prophylaxis (D1110) provided on June 12, 2019.You asked the Plan to reimburse the full amount forthe dental service. You say that you should have received an additional $41.24 reimbursement from the Plan.The Plan denied your request. The Plan says the claim was processed and paid correctly. The Plan says that the maximum allowance has been reached. The Plan also says that you are responsible for any amount above the dental coverage limit.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 Plan is not required to reimburse more than the maximum allowance of $250. The record shows that you the Plan paid $180 for the dental service on January 4, 2019. Additionally, the Plan paid $70 toward the dental services you received on June 12, 2019. Combined, these amounts paid by the Plan total the $250 maximum allowance.Therefore, we decided that the Plan does not have to reimburse the full amount forthe prophylaxis (D1110) provided on June 12, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a nuclear stress test provided on September 18, 2019.
You asked the Plan to waive the copayment for a nuclear stress test. You say that you were advised that he
would not be charged for this test. The Plan denied your request. The Plan says the correct copayment has been
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 for outpatient diagnostic tests/advanced diagnostic radiology services.
You have been asked to pay a $150 copayment for a nuclear stress test. A nuclear stress test falls within the
outpatient diagnostic tests/advanced diagnostic radiology 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 a nuclear stress test provided on September 18,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services providedon May 14, 2019.You askedthe 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 servicesat 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 servicesprovided on May 14, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe inpatient stay provided from September 26, 2019 through September 29, 2019.You asked the Plan to waive the copayment forthe inpatient stay. You say that there was inadequate service for the time you were there. You say that you cannot afford to pay. The Plan denied your request. The Plan says the copayment applied correctly.The rules say a plan mustdisclose 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 per day, days 1 to 7 at an in-network inpatient hospital.You have been asked to pay a $780 copayment for the inpatient stay. ($260/day x 3 days = $780). The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forthe inpatient stay provided from September 26, 2019through September 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve rhytidectomy and rhinoplasty (facial feminization surgery).
You asked the Plan to pre-approve the surgery. You say that this is detrimental to your mental health. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the case file does not support that rhytidectomy and rhinoplasty are medically reasonable and necessary for the enrollee in this case. 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 surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve rhytidectomy and rhinoplasty (facial feminization surgery).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on May 29, 2019.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says there is no network deficiency for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 forthe medical services provided to the enrollee by an out-of-network provider on May 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 29, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you did not
have out-of-network benefits.
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 August 29, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lumbar fusion surgery (63048, 63047, 22633, 63056).
You asked the Plan to pre-approve lumbar fusion surgery. You say that the services are medically necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve lumbar fusion surgery. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of a trial and failure of conservative measures for back pain. Criteria for fusion is not met. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lumbar fusion surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve lumbar fusion surgery (63048, 63047, 22633, 63056).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on September 6, 2019.You asked the Plan to pay forthe services. The Plandenied your request. The Plan says the enrollee was enrolled in hospice.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 date of service at issue in this appeal.Therefore, we decided that the Plan does not have topay forthe services provided on September 6, 2019.