Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the vision care services (V2020 V2200 V2781) received
February 18, 2021, from the out-of-network provider.
You asked the Plan to pay for the vision care services. You say that you were told you could submit a claim for
out-of-network coverage. The Plan denied your request. The Plan says your benefit does not include coverage
for routine vision services received outside off the Plan's vision care network.
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 received from a Plan-participating provider.
We looked at the file and the Plan's rules. You received the requested services outside of the Plan's vision care
network. Based on this information, we decided that the Plan's rules for coverage of the vision care services
have not been met. Therefore, we decided that the Plan does not have to pay for the vision care services
(V2020 V2200 V2781) received February 18, 2021, from the out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided following surgery.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the requested care is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for inpatient care have not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer found that an inpatient hospital stay is not medically needed after a routine lumbar laminectomy surgery. A 48-hour observational stay is most appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided following surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation with a hand orthopedic surgeon to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the consultation with a hand orthopedic surgeon. You say that you have seen this provider previously and would like to see him again. The Plan denied your request. The Plan says the provider is out-of-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. Therefore, we decided that the Plan does not have to pre-approve the consultation with a hand orthopedic surgeon 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 waive the copayment for the inpatient stay provided from December 21, 2018, through December 26, 2018.
You asked the Plan to waive the copayment for the inpatient stay. You say that your cardiologist said it was necessary to be transferred since the hospital was not able to do the procedure. You say that you should not be responsible for another charge and you cannot afford to pay this. 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 $360 copayment per day for days 1-5 and a $0 copayment per day for days 6-90 for each in-network admission.
You have been asked to pay an $1,800 copayment for the inpatient stay. ($360/day x 5 days = $1,800). The inpatient stay falls within the "Inpatient hospital care" benefit category. The Evidence of Coverage states the inpatient copayment applies to each admission. 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 inpatient stay provided from December 21, 2018, through December 26, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport (A0428) and ground mileage (A0425) provided on October 29, 2020.
You asked the Plan to pay for the non-emergent ambulance transport and ground mileage. The Plan denied your request. The Plan says ambulance transport to or from an outpatient office is not a Medicare covered benefit.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance transport and ground mileage. Our reviewer says that the documentation does not support that the ambulance services were medically reasonable or necessary for the enrollee. Our physician reviewer found that the documentation does not support that other means of transportation, such as a stretcher van, would be contraindicated for this enrollee. Our physician reviewer also found that the documentation does not support that the enrollee required expertise or special equipment during the transportation. 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 non-emergent ambulance transport and ground mileage have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport (A0428) and ground mileage (A0425) provided on October 29, 2020.
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 records provided support the need for LTACH care. The Plan denied your request. The Plan says LTACH care 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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee was admitted following aortic dissection. He has a history of coronary artery disease and prostate cancer. He is hypoxic and tachypneic and is considered clinically unstable. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by a provider at a tertiary facility.
You asked the Plan to pre-approve an office visit at a tertiary facility. You say that the requested provider has done several surgeries on you and you want to see him again. The Plan denied your request. The Plan says the medical notes do not show that these services cannot be done at a community level.
Medicare rules say that plans can require enrollees to get care from network providers. The requested provider in this case is at a Tertiary Care Center. The Plan has network providers available at a community level who can provide the items at issue in this appeal.
We found no exception that would require the Plan to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve an office visit to be provided by a provider at a tertiary facility.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dental services (D3331, D3348, D3332).
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested services are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve dental services (D3331, D3348, D3332).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on February 18, 2020.
You asked the Plan to pay for the laboratory test. You say that you are appealing the claim with medical records for further processing. The Plan denied your request. The Plan says prior authorization was required but 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 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 laboratory test provided by an out-of-network provider on February 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on August 6, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not covered.

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 pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no clinical rationale for the requested genetic testing. In addition, Medicare denies coverage when a laboratory assays two or more genes in a patient in parallel. Those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one CPT code must be submitted for the panel.

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on August 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation (A0425, A0428) received February 17, 2021.You asked the Plan to waive the copayment for the ambulance transportation. You say that the Plan should waive the copayment.The Plan denied your request. The Plan says the correct cost share 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 contrac twith the Plan clearly says that you must pay a $200 copayment for Ambulance Services. You have been asked to pay a $200 copayment for the ambulance transportation. The ambulance transportation falls 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 the ambulance transportation (A0425, A0428) received February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share amount for the complete series x-ray (D0210)
provided on March 4, 2021.
You asked the Plan to waive the cost share amount for the dental service. You say that the previous
representative had advised that this service would be covered 100%. The Plan denied your request. The Plan
says you pay 20% of the allowed amount for Class 2 Basic Services, including the complete series x-ray. The
Plan also says that the $17.25 coinsurance is correct.
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 and complete series x-ray is listed as a
covered service, there is a 20% coinsurance for this and other Class 2 Basic Services. Therefore, we decided
that the Plan does not have to waive the cost share amount for the complete series x-ray (D0210) provided on
March 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 29, 2020.

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.

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 pay for the testing. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no medical history provided other than listed diagnoses. Cardiac gene variant testing has limited clinical application at present and may be occasionally useful in more rare familial inherited cardiac conditions. No medical history is provided on the diagnosis of the condition or of a family history of cardiomyopathy suggestive of a possible familial inherited cardiac condition. In the absence of specific diagnostic information suggesting a familial component, cardiac gene variant testing is not currently recommended for general or routine use and would not be considered medically reasonable or necessary.

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment panel provided on September 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from February 13, 2021 through February 15, 2021.
You asked the Plan to waive the copayment for the inpatient stay. You say that the member was held in the hospital longer than necessary. You say that the delay caused the insurance to be billed more and the member to be charged more for a copayment. 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). The enrollee's contract with the Plan clearly says that enrollees must pay $275 per day for days 1-5 and $0 after day 5 each time you are admitted to an acute care hospital.
The enrollee has been asked to pay a $550 copayment for the inpatient stay. ($275/day x 2 days = $550). The inpatient stay falls within the "Inpatient hospital care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the inpatient stay provided from February 13, 2021 through February 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an osseous surgery (D4260) and nine bone replacement grafts (D4263 x9) to be rendered by an OON provider.

You asked the Plan to pre-approve the osseous surgery and bone replacement grafts. You say that you have been advised that this provider is in-network. The Plan denied your request. The Plan says you have requested that these services be rendered by an OON provider. The Plan also says that services are not covered by an OON provider.

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 covered when they are received OON. Therefore, we decided that the Plan does not have to pre-approve an osseous surgery (D4260) and nine bone replacement grafts (D4263 x9) to be rendered by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee's pain is not mostly localized to the low back.

The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. 

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 requested services. Our physician reviewer found that the enrollee sustained an L4 vertebral fracture. She also has spinal stenosis and degenerative disc disease. She had 2 epidural steroid injections with minimal benefit. She has not had interventions that address the L4 fracture. The request is for diagnostic facet blocks. The request does not meet the coverage criteria as there are two separate obvious pain generators, spinal stenosis and the L4 vertebral fracture. Therefore, the request is not medically reasonable or necessary.

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of implant body: endosteal implant (D6010) and the sinus augmentation with bone or bone substitutes via a lateral open approach (D7951) received January 14, 2021.
You asked the Plan to pay for the dental services. You say that the requested services should be paid for by the Plan. The Plan denied your request. The Plan says the requested services are not covered under your 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 pay for the surgical placement of implant body: endosteal implant (D6010) and the sinus augmentation with bone or bone substitutes via a lateral open approach (D7951) received January 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the lumbar-sacral orthosis to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the lumbar-sacral orthosis. You say that you need the brace for your back to keep your body straight to prevent twisting. The Plan denied your request. The Plan says the provider is out-of-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. Therefore, we decided that the Plan does not have to pre-approve the lumbar-sacral orthosis to be provided by an out of network (OON)provider.