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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found you do not require ongoing skilled nursing
services to safely and effectively provide medically necessary and reasonable treatment. Your functional level
and also your inability to accept redirection and confusion does not support that you require skilled therapy
services to safely and effectively provide medically necessary and reasonable treatment only in a SNF. It is not
medically reasonable and necessary to provide skilled nursing or skilled therapy services (or a combination of
these services) on a "daily basis." As a practical matter you do not require the necessary services on an
inpatient basis, in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the deductible for the routine foot care provided on January 9, 2019.
You asked the Plan to waive the deductible for the routine foot care. 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 that the correct cost share has applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that enrollees must pay a $0 copayment for Additional Routine Podiatry.
The Plan says you must pay $49.34 towards your 2019 deductible for the routine foot care. Based on the Plan
contract, however, you cannot be asked to pay more than a $0 copayment for the routine foot care. The Plan
contract clearly says that the deductible does not apply to routine foot care. Therefore, we decided that the Plan
has to waive the deductible for the routine foot care provided on January 9, 2019.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on January 9, 2020.
You asked the Plan to pay for the pathology services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
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 pathology services provided on January 9, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on December
2, 2019.
You asked the Plan to waive the copayment for the ambulance. You say that you were told you would not be
responsible for the ambulance transportation. The Plan denied your request. The Plan says you have been
charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $225
copayment for Medicare-covered ambulance services per day.
You have been asked to pay a $225 copayment for the ambulance. The ambulance 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 ride
provided on December 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services provided on April 11, 2019.
You asked the Plan to waive the copayment for the laboratory services. You say that you should not be liable for the cost share because the laboratory services were a part of your annual wellness exam. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each Medicare-covered laboratory test at an in-network outpatient facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $40 copayment for the laboratory services.
You have been asked to pay a $24.68 copayment for the laboratory services. The laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows a diagnosis code for abnormal tumor markers which makes the laboratory work diagnostic in nature.
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 laboratory services provided on April 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two core buildups, including any pins when required (D2950 x2) provided on February 17, 2020. You asked the Plan to pay for the core buildups. You say that you feel you are not able to have a crown without a core buildup. You also say that other insurance companies cover core buildup. The Plan denied your request. The Plan says this service is not covered 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 two core buildups, including any pins when required (D2950 x2) provided on February 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 6, 2020 by an out of network (OON) provider. You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care. 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 laboratory services provided on January 6, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0260).
You asked the Plan to pre-approve the semi-electric hospital bed. You say that please see the attached clinical notes to justify the bed. The Plan denied your request. The Plan says the request for the semi-electric hospital bed is not medically necessary.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found The documentation is not clear that the enrollee requires positioning not feasible in an ordinary bed. It is not clear what attempts have been made that are not feasible for repositioning. The enrollee's condition does not require immediate for frequent changes in body position or attachments than cannot be fixed and use on an ordinary bed. The semi-electric hospital bed is not medically necessary for this enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve the semi-electric hospital bed (E0260).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-covered chiropractic services (99203, 97014 and 97012) provided from December 18, 2019 to December 30, 2019.
You asked the Plan to pay for the non-covered chiropractic services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the non-covered chiropractic services (99203, 97014 and 97012) provided from December 18, 2019 to December 30, 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 enrollee will receive the appropriate level of care in the IRF. You say that a further delay care will have a detrimental effect on the enrollee's safety, ability to recover to the fullest extent, and discharged to a community setting and averting unplanned readmissions.The Plan denied your request. The Plan says the care need to be provided in a hospital. The Plan says that the enrollee does not meet the criteria for coverage, as the care needed is not complex enough and can be provided in a lower level of care.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 the enrollee was medically stable with no evidence of need for supervision by a physical medicine and rehabilitation physician. There is no evidence of a need for acute rehab nursing care. The enrollee may benefit from further physical therapy and occupational therapy, but does not require an intensive therapy program. An IRF admission is not medically necessary based on the enrollee's current functional status and medical stability. The information provided does not support that the enrollee requires, or will be able to tolerate, 3 hours of therapy per day. The enrollee is newly on dialysis; this can be provided at a lower level of care. The enrollee's rehab needs do not require specialized therapy services or equipment. The enrollee's rehab needs can be met at a lower intensity setting such as in a skilled nursing facility (SNF). We looked at this physician's review, thefile, 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 laboratory services provided on May 9, 2019.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the lens upgrades you received on January 30, 2020.You asked the Plan to pay for the lens upgrades. You say that you were never told that this would not be covered.The Plan denied your request. The Plan says this is not a covered benefit.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 does not cover lens upgrades.We looked at the file and the Plan's rules. While the Plan does cover eyeglasses and standard lenses, lens upgrades are not a covered benefit.Therefore, we decided that the Plan does not have to pay for the lens upgrades you received on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 9, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two extractions provided on January 14, 2020.
You asked the Plan to pay for the extractions. You say that prior to the service being rendered, you spoke with a plan representative to confirm that the treating provider was in network and that you were covered in some capacity for the service. You also say that the plan representative assured you that you had up to $750 in coverage. The Plan denied your request. The Plan says this service is not covered under your plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The records show that the call records indicate that there was not any mention of extractions being covered. Therefore, we decided that the Plan does not have to pay for the two extractions provided on January 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on November 12, 2019 by an out of network dentist.You asked the Plan to pay for the dental services. You say that a plan representative advised that the dentist in this case was in network. You also say that had you been advised otherwise, you would not have scheduled an appointment with him.The Plan denied your request. The Plan says the provider in this case was not a network provider at the time that you received the dental services. The Plan says that dental services that you receive out of network are not covered. 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 services you received are not covered when you receive them out of network.Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) and the prophylaxis (D1110) provided on November 12, 2019by an out of network dentist.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the cataract surgeries provided on November 18, 2019 and November 21, 2019.
You asked the Plan to waive the copayments for the cataract surgeries. You say that you were told that Medicare would pick up all the monies and that you would not have to pay any monies out of pocket. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. You have been asked to pay a $295 copayment for each of the cataract surgeries. The cataract surgeries fall within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory" 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 cataract surgeries provided on November 18, 2019 and November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine and administration provided on January 13, 2020.
You asked the Plan to pay for the shingles vaccine and administration. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the shingles vaccine and the administration of the shingles vaccine are not covered under your Medicare Part B benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine and administration. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine and administration. Therefore, we decided that the Plan does not have to pay for the shingles vaccine and administration provided on January 13, 2020.
Benefits for the shingles vaccine and administration 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on December 24, 2019.
You asked the Plan to waive the copayment for ambulance transport. You say that the enrollee was not aware of this copayment. The Plan denied your request. The Plan says the copayment amount the enrollee is being charged is correct.
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 $250 copayment for ambulance transport. The enrollee has been asked to pay $250 copayment for ambulance transport. Ambulance transport falls within the Ambulance Services 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 ambulance transportation provided on December 24, 2019.