Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveoffice visits and treatment to be provided by an out of network (OON) provider.You asked the Plan to pre-approvean office visit and treatment. You say that you would like to keep seeing this doctor. You say that your doctor also goes to this doctor and the doctor understands your family's medical history.The Plan denied your request. The Plan says these services can be provided at KP Pulmonary.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that thePlan 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-approveoffice visits and treatment to be provided by an out of network (OON) provider.
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 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 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 IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found you do not require the intensity of services provided at an IRF. Specifically, you are
not shown to require, or to be able to perform, fifteen hours per week of rehabilitative services with regular
physician evaluation. Your care needs can be met at a lower level of 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 3, 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 claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay for the drug testing rendered on April 3, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to payforthe root canal provided on March 5, 2018 and the retainer crowns, porcelain fused to high noble metal (D6750 x 6), and the pontics, porcelain fused to high noble metal (D6240 x 3) provided on July 16, 2018 by the in network provider.You asked the Plan to pay forthe root canal, 6 additional retainer crowns and the pontics. You say that your dental work was very extensive and started in September 2017 under a different dental plan. You say that your new plan is refusing to pay for the services. You also say that you are unable to afford the charges from March 5, 2018 and July 16, 2018.The Plan denied your request. The Plan says that authorization was not obtained before you received the root canal. The Planalsosays that the frequency limitfor crowns and pontics havebeen exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers the dental services when the services are medically necessary and reasonable.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is providedthat the services will not be covered. The Planfollows these rules.We looked at the case file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met.Additionally, the Evidenceof Coverage clearly states that prior authorization is the responsibility of the provider. The enrollee should not be held liable for the provider's mistake.Therefore, we decided that the Plan has to pay forthe root canal provided on March 5, 2018 and the retainer crowns, porcelain fused to high noble metal (D6750 x 6), and the pontics, porcelain fused to high noble metal (D6240 x 3) provided on July 16, 2018 by the in network provider.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide toopen the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a vision exam provided on October 21, 2019.
You asked the Plan to waive the copayment for the vision exam. The Plan denied your request. The Plan says the correct cost share was applied to the claim.
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 copayment for vision care for subsequent visits. You have been asked to pay $40 copayment for the vision exam. The vision exam falls within the vision 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 for a vision exam provided on October 21, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for MRI's provided on October 8, 2019.
You asked the Plan to waive the copayments for MRI's. You say that you were told that you would only owe one copayment for MRI's received on the same day. 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 $125 copayment for each MRI. You received two MRI's on October 8, 2019. Therefore, you are responsible to pay a $125 copayment per each MRI. The total amount you owe is: $250.00. You have been asked to pay the total copayment amount of $250.00 for MRI's. MRI's fall 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 MRI's provided on October 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hypoglossal nerve stimulation.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that procedure code 0466T is considered not medically necessary.We looked at the file and Medicare rules. The services at issue are hypoglossal nerve stimulation described by code 0466T. These services are denied by Medicare as not medically necessary.Therefore, we decided that the Plan does not have to pre-approve hypoglossal nerve stimulation
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Ultra Blue test strips for the enrollee.You asked the Plan to pre-approve these services. You say that this is medically necessary.The Plan denied your request. The Plan says that this is not a preferred strip.The Plan must follow Medicare rules. Medicare rules say that plans may limit enrollees to preferred providers.The items at issue are OneTouch Ultra Blue test strips. The requested provider is not a preferred provider with the Plan for diabetic supplies. ACCU-CHEK and Trividia are the preferred providers.Therefore, we decided that the Plan does not have to pre-approve OneTouch Ultra Blue test strips for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 21, 2019.You asked the Plan to pay for the laboratory 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 laboratory services provided on September 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOlumiant for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugsrequested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveOlumiant for the enrollee.Benefits for these servicesmay be available under Medicare Part D.Contactthe 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-approve home visits for assistance with activities of daily living and personal care (99509).You asked the Plan to pre-approve home visits for assistance with activities of daily living and personal care. You say that the enrollee is bed bound and needs assistance for activities of daily living.The Plan denied your request. The Plan says the requested services are not part of a skilled treatment plan.The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. Custodial care is not covered.We looked at the file and Medicare rules. The requested home health services are custodial in nature. The documentation does not show that the enrollee has any skilled nursing or therapy needs. Based on this information, we decided that Medicare rules for coverage of home visits for assistance with activities of daily living and personal care have not been met.Therefore, we decided that the Plan does not have to pre-approve home visits for assistance with activities of daily living and personal care (99509).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided November 1, 2019. You asked the Plan to pay for the chest x-ray. You say that the X-ray was medically necessary.The Plan denied your request. The Plan says pre-operative x-rays in asymptomatic patients are not covered.The Plan follows Medicare rules. Medicare rules say that pre-procedural chest X-rays in the absence of symptomatic pulmonary or cardiac diseases are generally 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 pay for the chest x-ray. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the enrollee had a chest-x-ray as part of a pre-operative evaluation for a lithotrpsy. The enrollee has no documented cardiac or pulmonary history or symptoms. An X-ray was not medically necessary 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 chest x-ray have not been met.Therefore, we decided that the Plan does not have to pay fora chest x-ray (71046) provided November 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the urinalysis provided on September 24, 2019.
You asked the Plan to pay for the laboratory service. You say that the service was an emergency. You say that you did not have time to request an authorization for the service. The Plan denied your request. The Plan says authorization was not obtained before the service was provided to the enrollee. The Plan says the services were not urgent or emergent in nature. The Plan also says the service 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. You are 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 the urinalysis provided on September 24, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on October 10, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that if you weren't taken off your medication you would not have had these expenses. You say that you shouldn't have to pay the bill. 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 $90 copayment for each hospital emergency room visit. You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category. The records show that you were treated in the ED. 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 ED visit provided on October 10, 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 is with a diagnosis of lymphedema and a urinary tract infection and was admitted to an acute hospital and recently discharged home in stable condition with deconditioning and receiving home health physical therapy and skilled nursing. An admission screening on 2/20/20 indicated that she was requiring moderate assist for bed mobility and transfers and basic activities of daily living with maximum assist and dressing with moderate assist. Physical therapy and occupational therapy notes dated 2/16/20 indicated that she requires maximum assistance for transfers, and has difficulty walking. The enrollee required moderate to maximum assist for bathing and dressing. She was reported not oriented to place or person. Based on review of the available records, the enrollee does not meet criteria for IRF admission. The enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehab physician or needs acute rehab nursing care. She may benefit from further physical therapy and occupational therapy but does not require an intensive therapy program. IRF admission is not medically necessary based on her current medical stability. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe acupuncture treatment (97813, 97814), and the manual therapy techniques (97140) provided  from August 27, 2019 to August 29, 2019.You asked the Plan to pay forthese services. You say that you are requesting a reconsideration of the Plan's denial to reject payment for services that were pre-approved.The Plan denied your request. The Plan says these services are not a covered benefit under your contractual policy.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 for the acupuncture treatment (97813, 97814), and the manual therapy techniques (97140) provided August 27, 2019 to August 29, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to waive the cost sharing amounts the prophylaxis (D1110), comprehensive oral evaluation (D0150), the bitewing x-rays (D0272), and the additional periapical x-ray (D0230) provided on October 10, 2019.
You asked the Plan to review their decision. The Plan says your claim was processed correctly.
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 information on the reconsideration background data form (RBDF) and the case file do not match. We requested a corrected case file but nothing was received. Therefore, we decided that the Plan has to waive the cost sharing amounts the prophylaxis (D1110), comprehensive oral evaluation (D0150), the bitewing x-rays (D0272), and the additional periapical x-ray (D0230) provided on October 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for anti-reflective coating and photochromic lenses provided on October 24, 2019.You asked the Plan to pay for the eyeglass lenses. You say that you do not have enough money to pay for the lenses. The Plan denied your request. The Plan says anti-reflective coating and photochromic lenses are lens enhancements that are not a covered benefit.Medicare generally does not cover eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.We looked at the file and the Plan's rules. Anti-reflective coating and photochromic lenses are lens enhancements, which are not a covered benefit. Therefore, we decided that the Plan does not have to pay for anti-reflective coating and photochromic lenses provided on October 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Inspire nerve device.
You asked the Plan to pre-approve the Inspire nerve device. You say that this is medically necessary as CPAP
does not work for the member. The Plan denied your request. The Plan says the nerve stimulator 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 Inspire nerve device. Our reviewer
says that the documentation is insufficient to support that the use of a hypoglossal nerve stimulator is medically
necessary and reasonable to address the enrollee's OSA and disturbed sleep. Our physician reviewer found
there is no documentation that the enrollee used a CPAP or an oral appliance, for how long, with what level of
compliance, with what kind of adjustments or with what level of effectiveness.
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 Inspire nerve device have not been met. Therefore, we decided that the Plan
does not have to pre-approve an Inspire nerve device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prodigy No Coding test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee already has and uses a Prodigy meter. The Plan denied your request. The Plan says there is no medical reason documented that the enrollee is medically unable to use the Plan preferred meters and supplies.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Prodigy No Coding test strips.