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

We decided that the Plan does not have to waive the cost share for the regadenoson injection and myocardial perfusion imaging provided on February 5, 2020.
You asked the Plan to waive the cost share for the regadenoson injection and myocardial perfusion imaging. You say that you were informed you were responsible for $100. You say that you cannot afford to pay. 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 20% coinsurance for Medicare Part B-covered chemotherapy drugs and other Medicare Part B-covered drugs and a $100 copayment for Medicare-covered nuclear medicine at a freestanding provider. You have been asked to pay a total of $140.31 for the regadenoson injection and myocardial perfusion imaging.
Service
Allowed Amount
Standard Cost
Member Liability
Regadenoson Injection
$201.55
20%
$40.31
Myocardial Perfusion Imaging
$394.35
$100
$100
TOTAL:
$140.31
The regadenoson injection falls within the "Medicare Part B Prescription Drugs" benefit category. The myocardial perfusion imaging falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for the regadenoson injection and myocardial perfusion imaging provided on February 5, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on December 18, 2019 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you do 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. Review of the file show that you received the dental services on December 18, 2019 from an out-of-network provider. Your EOC states, Preventive Dental services from a Dental Participating Provider in your dental plan network are covered under your dental plan. 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 the dental services provided on December 18, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 14, 2020 by an out of network (OON) provider.You asked the Plan to pay for outpatient services. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with the Plan. 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 the medical services provided on January 14, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve calcipotriene ointment.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug 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 calcipotriene ointment.
Benefits for self-administered drug 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: Favorable

We decided that the Plan has to pay forthe physician services provided on December 26, 2019.You asked the Plan to pay forthe physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that you previously had a screening on July 18, 2019, which was billed and paid. The Plan says that the preventative exam in this case is denied due to exceeding the benefit maximum for the 2019 calendar year.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 provided that the services will not be covered. The Plan follows these rules.You were referred for the physician services by a contract provider. The file does not show that the Plan provided notice that the physician services would not be covered. Under Medicare rules, this means the physician services is considered approved by the Plan. The provider billed CPT code 99397, which the Plan denied as exceeding benefit limits. The definition of CPT code 99397 is Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 65 years and older. The Plan has not provided any documentation showing that the provider billed this code specifically for a pap test or pelvic exam. The Plan's EOC does not say that CPT code 99397 would not be covered if billed by a contracted provider.Therefore, we decided that the Plan has to pay forthe physician services provided on December 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on December 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you have been seeing this doctor since 2010. The Plan denied your request. The Plan says there are in-network providers available for these services. The plan says that no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit provided on December 30, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Plantopre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The PlansaysLTACHs do not provide clinical advantage over non LTACH acute care hospitals.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 askedour 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 consideredmedically reasonable and necessary in this case. Our physician reviewer found the review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. 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 requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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 LTACHservices have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does nothave to pre-approvean additional quantity of non-sterile gloves.You asked the Plan to pre-approvean additional quantity of non-sterile gloves. You say that you do not have enough gloves for the representative to feed you, bathe you, and do other duties. The Plan denied your request. The Plan says additional boxes of non-sterile gloves are not medically necessary.The Plan covers all items that Medicare covers. Medicare rules state that non-sterile disposable gloves are not covered because they are hygienic items that are non-reusable. WhileMedicare does not cover non-sterile gloves for your condition the Plan covers 2 boxes a month. The Plan's coverage rules apply.Therefore, we decided that the Plan does not have to pre-approvean additional quantity of non-sterile gloves
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99232) provided August 30, 2019.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says Original Medicare is liable for payment for these services.
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 physician services (99232) provided August 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forimmediate denture -mandibular (D5140), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on December 16, 2019 by an out-of-network provider.You asked the Plan to pay forthe dental services. You say that the dentures and the provider were approved.The Plan denied your request. The Plan says you do 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.Review of the file show that you received immediate denture -mandibular (D5140), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140)  on December 16, 2019 by an out-of-network provider. Your EOC states, services performed by an out-of-network dentist if your plan does not have out-of-network coverage. The requested provider in this case is not anetwork 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. Furthermore, these services are not listed in your EOC as covered benefits.Therefore, we decided that the Plan does not have to pay forimmediate denture -mandibular (D5140), extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) and extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided on December 16, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve a radiation therapy treatment plan of 28 fractions of 3-dimensional conformal and 6 fractions of electrons/photons image guided radiation therapy (IGRT).
You asked the Plan to pre-approve radiation therapy. You say that the enrollee has cancer and needs to start a treatment plan right away. The Plan denied your request. The Plan says that the denial of authorization for he requested services is correct, because studies do not support this type of treatment.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve radiation therapy. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found image-guided radiotherapy (IGRT) for whole breast radiation is an accepted standard for exceptional circumstances such as difficult patient setup, prior radiation necessitating more accurate localization, or abutment of the field against a critical organ. Routine use of IGRT is not within accepted standards of care and no rationale for IGRT has been provided. However, it is plausible that with this enrollee's obesity, IGRT could be considered necessary as daily setup could be compromised without IGRT. A high body-mass index can be considered an exceptional circumstance as reliability of skin marks is less accurate. As such, IGRT would be offered in accordance with accepted standards 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 radiation therapy have been met. Therefore, we decided that the Plan has to pre-approve a radiation therapy treatment plan of 28 fractions of 3-dimensional conformal and 6 fractions of electrons/photons image guided radiation therapy (IGRT).
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 to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision services to be provided by an out-of-network provider.
You asked the Plan to pre-approve the requested services. You say that the requested provider was recommended by your physician. The Plan denied your request. The Plan says low vision aids are a benefit exclusion.
The Plan must follow Medicare rules. The rules say that Medicare does not cover low vision aids.
The services you asked the Plan to pre-approve are not covered by Medicare under any condition. Therefore, we decided that the Plan does not have to pre-approve vision services to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral for a left total knee joint replacement with an out-of-network provider.
You asked the Plan to pre-approve the referral. You say that you have been suffering for a while, and this procedure is needed to improve your quality of life. The Plan denied your request. The Plan says these services are available 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 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 at the in-network rate. You can choose to receive these services, but they will pay at the higher POS rate. Therefore, we decided that the Plan does not have to pre-approve a referral for a left total knee joint replacement with an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the anesthesia services provided on November 18, 2019, by an out-of-network provider.
You asked the Plan to reduce the cost share for the provided services. You say that you did not understand that the services could be considered out-of-network. The Plan denied your request. The Plan says the claim paid properly consistent with your out-of-network benefits.
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 50% of the Medicare-allowed amount for out-of-network services. You have been asked to pay 50% of the Medicare-allowed amount for out-of-network services. 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 reduce the cost share for the anesthesia services provided on November 18, 2019, by an out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 21, 2019.
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford the charges and you feel that the services were indeed an emergency. 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 $270 copayment for ambulance services. You have been asked to pay a $270 copayment for ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on November 21, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional mileage for your routine transportation.
You asked the Plan to pre-approve additional miles. You say that you have no other way to make it to your appointment. The Plan denied your request. The Plan says your benefit only allows 50 miles.
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. Routine transportation for over 50 miles was requested. We looked at your request, the records in the case file, and the rules. The Plan only covers transportation for up to 50 miles. 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 mileage for your routine transportation.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Magnetic Resonance Imaging (MRI) of the Spine (72148) provided on June 5, 2019.
You asked the Plan to pay for the MRI. You say that the services were medically necessary. The Plan denied your request. The Plan says there was no pre-authorization. There were network providers available.
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 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 the Magnetic Resonance Imaging (MRI) of the Spine (72148) provided on June 5, 2019.