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

We decided that the Plan does not have to waive the copayment for diagnostic colonoscopy (45835) provided
September 16, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that this was a routine colonoscopy.
You're being charged for a diagnostic colonoscopy because you had polyps removed. You feel this should be
charged as a routine with no copay. The Plan denied your request. The Plan says this claim was processed and
the correct copayment was applied per the Evidence of Coverage.
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 $100
copayment for each Medicare covered outpatient surgery.
You have been asked to pay $100 copayment for the colonoscopy. The colonoscopy falls within the Outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for diagnostic colonoscopy (45835) provided
September 16, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvedental services (D6240, D6750).You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says these services are not covered by the 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 pre-approvedental services (D6240, D6750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe SMART.You asked the Plan to pre-approvethe SMART. You say that this service is medically necessary.The Plan denied your request. The Plan says this service is not a covered supplemental 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-approvethe SMART.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveenteral nutrition.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the reviewed documentation indicates that you have not lost weight as her BMI is over 18.5. You have gained weight. You are also tolerating 60% of oral intake. The review has determined that you do not meet the criteria for this request. 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 services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveenteral nutrition.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvechiropractic services to be provided by an out of network (OON) provider.You asked the Plan to pre-approvechiropractic services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services can be provided by a network provider.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvechiropractic services to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the exam or eyeglass allowance for eyeglasses purchased on June 30, 2020 from an out of network provider.
You asked the Plan to pay for the eyeglass allowance. You say that you would like the Plan to provide some portion of payment. The Plan denied your request. The Plan says you did not use a network provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that you must use the preferred provider. The provider in this case is not a network provider with the Plan. The Plan has a preferred provider. 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 exam or eyeglass allowance for eyeglasses purchased on June 30, 2020 from an out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 28, 2020 to
September 2, 2020 by an out of network (OON) provider.
You asked the Plan to pay for surgical services. You say that you are appealing with supporting records. 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 authorization was not 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 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 the medical services provided on August 28, 2020
to September 2, 2020 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D6740, D6245, D9972).You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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 Plandoes not haveto pre-approvedental services (D6740, D6245, D9972).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvefoot orthotics.You asked the Planto pre-approvefoot orthotics. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no previously approved authorization for a leg brace and custom shoesor inserts.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 Plandoes not haveto pre-approvefoot orthotics
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefull mouth debridement to enable comprehensive evaluation and diagnosis (D4355).You asked the Plan to pre-approvethe dental service. You say that you were advised by a plan representative that you have coverage for deep cleanings. You say thatThe Plan denied your request. The Plan says full mouth debridement to enable comprehensive evaluation and diagnosis is not covered on the same day or within 1 year of a periodic or comprehensive oral evaluation.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicarecoverage. 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 service is not covered on the same day or within 1 year of a periodic or comprehensive oral evaluation. The record shows that the Plan paid for a comprehensive oral evaluation that you received on November 24, 2020, less than 1 year ago.Therefore, we decided that the Plan does not have to pre-approvefull mouth debridement to enable comprehensive evaluation and diagnosis (D4355).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the chemotherapy administration provided on July 2, 2020.You asked the Plan to waive the coinsurance for the chemotherapy administration. You say that you should not be charged a coinsurance. The Plan denied your request. The Plan says the coinsurance was charged 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the chemotherapy administration. The total allowed amount is $91.29. The total amount you are being asked to pay is $18.26 ($91.29 x 20% = $18.26). Chemotherapy administration falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the chemotherapy administration provided on July 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require transfer to LTACH.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. The patient appears to be more stable but requires additional short-term acute care services which can safely be administered at the current facility. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided from May 29, 2020 through July 20, 2020. You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says generally speaking, the enrollee must use network providers to receive covered care, except for emergency care provided in a hospital emergency room worldwide, urgently needed services as are commonly provided in an urgent care center, and out-of-area renal dialysis received from any Medicare-certified dialysis provider throughout the U.S. or if the enrollee is in need of specialized care that is not available within the Plan's provider network when such care is prior authorized in advance by 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 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 subsequent nursing facility care provided from May 29, 2020 through July 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing services.
You asked the Plan to pre-approve the continued skilled nursing services. The Plan denied your request. The
Plan says your request does not meet Medicare guidelines because there are no noted daily skilled complex
nursing or therapy needs which would meet the guidelines for continued SNF services. The Plan also says that
while you may benefit from continuing physical, occupational, and speech therapy, the records do not support
the need for daily therapy on an inpatient basis.
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 the continued skilled nursing services.
Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you
do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled
professional nurse. You do not have daily skilled therapy needs that require the specialized skill, knowledge,
and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy
on an inpatient basis in a SNF setting.
We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs,
these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of
the continued skilled nursing services have not been met. Therefore, we decided that the Plan does not have to
pre-approve continued skilled nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea continuous glucose monitor.You asked the Planto pre-approvethe monitor. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not covered for the enrollee's condition. 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 monitor. Our reviewer says that the requested monitor is not considered medically reasonable and necessary in this case. Our physician reviewer found in this case you are not maintained on insulin therapy. You have not been using insulin multiple times (3 or more) a day. Your treatment does not require frequent adjustment on the basis of testing results.We looked at this physician's review, the file, and Medicare rules. Based on thisinformation, we decided that Medicare rules for coverage of the monitor have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea continuous glucose monitor.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network mental health provider.
You asked the Plan to pre-approve the referral. You say that this provider is the right fit for your needs. The Plan denied your request. The Plan says the services are available from other providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network mental health provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist visit provided on June 1,
2020.
You asked the Plan to waive the copayment for the specialist visit. You say that you feel you should not be
responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied
your request. The Plan says you received services provided by a specialist on the date of service at issue in this
appeal. The Plan says that the correct copayment has applied per your contract with the Plan.
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 $45
copayment for each covered visit or consultation in an outpatient location with a specialist.
We looked at the file, the Plan's contract and Medicare rules. The file shows that you received services
provided by a specialist on June 1, 2020. You have been asked to pay a $45 copayment for the specialist visit.
The specialist visit falls within the Physicians/Practitioner 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 the specialist visit provided on June 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral for eyeglasses with an out-of-network provider.You asked the Planto pre-approvethe referral. You say that you did not understand that you were limited to network providers.The Plandenied your request. The Plansaysthere is no coverage if services are not provided by a contracted provider.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when the services are rendered by a network provider.We looked at the file and the Plan's rules. The requested provider is not in the plan's network. Based on this information, we decided that the Plan's rules for coverageof the referral have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea referral for eyeglasses with an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral exam with dental code D0140 provided on September 9, 2020.
You asked the Plan to pay for dental code D0140. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says dental code D0140 is not covered under your supplemental dental 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, dental code D0140 is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral exam with dental code D0140 provided on September 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor.You asked the Plan to pre-approvea continuous glucose monitor. You say that this should be covered due to Covid-19 guidance.The Plan denied your request. The Plan says the criteria for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met.Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveincontinence supplies.You asked the Planto pre-approveincontinence supplies. You say that the enrollee's incontinence is due to his treatment for prostate cancer. You believe that coverage for the incontinence supplies is appropriate.The Plandenied your request. The PlansaysMedicare does not cover these items.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plandoes not haveto pre-approveincontinence supplies.