Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist services and outpatient rehabilitation services provided on January 5, 2021.
You asked the Plan to waive the copayments for specialist services and outpatient rehabilitation services. You say that you were told that you would only owe a $20 copayment for acupuncture services. 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 $50 copayment for specialist services.
Your contract with the Plan also clearly says that you must pay a $40 copayment for outpatient rehabilitation services. You received specialist services on January 5, 2021. Therefore, you are responsible to pay the $50 copayment. You received outpatient rehabilitation services on January 5, 2021. Therefore, you are responsible to pay the allowed amount of $31.95, which is less than the $40 copayment. The total amount you owe is: $81.95.
You have been asked to pay the total copayment amount of $81.95 for specialist services and outpatient rehabilitation services. Specialist services fall within the physician/practitioner services, including doctor's office visits benefit category. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for specialist services and outpatient rehabilitation services provided on January 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve GenVisc injections (J7320).
You asked the Plan to pre-approve GenVisc. You say that GenVisc is medically necessary. The Plan denied
your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is
due and the amount of payment.
We looked at the file and Medicare rules. Insufficient documentation was provided. No medical records were
provided to support the request. Based on this information, we decided that Medicare rules for coverage of
GenVisc have not been met. Therefore, we decided that the Plan does not have to pre-approve GenVisc
injections (J7320).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis Emu.
You asked the Plan to pre-approve Restasis Emu. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Restasis Emu is not covered under the enrollee's Medicare Part B benefit.
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 Restasis Emu.
Benefits for Restasis Emu 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided on February 17, 2021.
You asked the Plan to pay for the full mouth debridement. You say that the dental procedure you received in 2020 was the same as the procedure you received in 2021. You also say that you would like the Plan to pay for a cleaning, which is covered by your plan. 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 full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided on February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says the enrollee does not
have complex medical or intensive rehab needs.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
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 physician reviewer found
that the enrollee was admitted to the acute hospital for seizures after a recent stroke and for respiratory failure.
Her medical conditions are stable. There are no complex nursing needs. She does not require treatment by
multiple therapies, including either physical or occupational therapy, in an intensive rehab therapy program.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 you cannot function without these rehab services. The Plan denied your request. The Plan says your care requirements are routine in nature going forward and do not appear to require a team of providers on a daily basis. The care you require can safely be provided in another setting.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 that your medical conditions are stable and there are no complex nursing or
rehabilitation needs. There is no documented need for an intensive therapy program, and medically necessary
services can be provided in a different level of care. There is not a reasonable expectation that you will be able
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services provided on December 30, 2020.
You asked the Plan to pay for the ambulance services. You say that when the ambulance came, the medical staff checked your blood oxygen level, and it was very low, and they needed to take you to the hospital right away. You say that you were not prepared mentally, and you rejected the service. You say that later, under the pressure, you let them take you to the hospital. The Plan denied your request. The Plan says that first responder/assessment at scene is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided us with the ambulance medical records so we could determine if you were transported to the hospital as you have stated in your appeal. Therefore, we decided that the Plan has to pay for ambulance services provided on December 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin-based composite (D2392), core buildup, including any pins when required (D2950), and one retainer crown (D6750) provided on October 19, 2020.
You asked the Plan to pay for the resin-based composite, core buildup, and retainer crown. You say that you paid the provider in full, but only received $1,000 back. The Plan denied your request. The Plan says your benefit has been exhausted.
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 Plan also offers an annual maximum benefit of $1,000 every year. The contract says that after the annual maximum is exhausted, any remaining charges are your responsibility. The record shows that you met the annual maximum benefit while processing this claim for the October 19, 2020 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the resin-based composite (D2392), core buildup, including any pins when required (D2950), and one retainer crown (D6750) provided on October 19, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the service is medically necessary. The
Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 does not require services at the LTACH that are not available at the acute
care hospital where currently receiving 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 the LTACH services have not been met. Specifically, medically necessary
services are being obtained at the enrollee's current level of care. There is no service available at the LTACH
that they are not already receiving. This means admission into a LTACH is not medically necessary. Therefore,
we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories.
You asked the Plan to pre-approve group 3 power wheelchair. You say that this chair will assist with your condition and relieve the pressure from your legs and spine. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because your mobility limitation is not due to a progressive neurological condition, myopathy, or congenital skeletal deformity.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to: 1. A neurological condition; 2. Myopathy; or 3. Congenital skeletal deformity. The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair with accessories.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Premarin tablets.
You asked the Plan to pre-approve Premarin tablets. You say that you need this medication to avoid allergic reactions to a different medication. The Plan denied your request. The Plan says Premarin tablets are not covered by the enrollee's Medicare Part B benefit.
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 Premarin tablets.
Benefits for Premarin tablets 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Belladonna and Opium suppository provided from January 19, 2021, to January 20, 2021.
You asked the Plan to pay for the Belladonna and Opium suppository. You say that the enrollee could not self-administer this drug because he was sedated. The Plan denied your request. The Plan says the Belladonna and Opium suppository is a self-administered drug, and is not covered in an outpatient hospital setting.
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 pay for the Belladonna and Opium suppository provided from January 19, 2021, to January 20, 2021.
Benefits for the Belladonna and Opium suppository 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: Unfavorable

We decided that the Plan does not have to waive the coinsurance for air assisted head traction billed on August 19, 2020.
You asked the Plan to waive the coinsurance for the air assisted head traction. You say that you would like reconsideration because you believe you were misled by the provider as you were told this DME required a one-time payment. The Plan denied your request. The Plan says you pay a 10% coinsurance for covered items and related supplies.
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 10% copayment for Durable Medical Equipment.
You have been asked to pay a 10% coinsurance for the air assisted head traction. You have been asked to pay $5.99. The allowed amount for this equipment is $59.87. 10% of $59.87 is $5.99. You have been asked to pay the correct coinsurance. The air assisted head traction falls within the Durable Medical Equipment 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 air assisted head traction billed on August 19, 2020.
Your complaint about being given misleading information about your rental agreement is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on December 30, 2020.
You asked the Plan to waive the copayment for an ultrasound. You say that you were not aware that you would owe a $100 copayment for an ultrasound. 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 $100 copayment for diagnostic procedures and tests including ultrasounds. You have been asked to pay a $100 copayment for an ultrasound. An ultrasound 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 copayment for an ultrasound provided on December 30, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional non-emergency transportation rides.
You asked the Plan to pre-approve the additional non-emergency transportation rides. You say that you would
like more rides to be approved for coverage. The Plan denied your request. The Plan says you have exhausted
your non-emergency transportation services benefit.
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. The Plan covers a maximum of 24 one-way trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to pre-approve additional non-emergency transportation rides.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Dexcom sensors (K0553) provided on February 18, 2021.
You asked the Plan to waive the coinsurance for Dexcom sensors. You say that when you were with a previous Medicare plan you had no payments or deductibles. The Plan denied your request. The Plan says the correct copayment was applied.
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-covered durable medical equipment and supplies. You have been asked to pay $44.64, or 20% of the Medicare-allowed charge of $223.22, for Dexcom sensors. Dexcom sensors fall within the "Durable medical equipment (DME) and related 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 coinsurance for Dexcom sensors (K0553) provided on February 18, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric admission.
You asked the Plan to pre-approve inpatient psychiatric admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric admission. Our reviewer says that the service is not medically necessary. Our physician reviewer found it was not expected this
enrollee would improve in a reasonable period of time nor was it medically necessary to receive psychiatric care at an inpatient level. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric admission have not been met. Specifically, medically necessary services could be provided at a lower level of care. This means inpatient psychiatric admission is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric admission.
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary or reasonable.
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 does not require services at the LTACH that are not available at the acute care hospital where currently receiving 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 the LTACH services have not been met. Specifically, the enrollee is receiving medically necessary services at their current level of care. There are no extra services available at a LTACH that they are not already receiving. This means admission into a LTACH is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on March 10, 2021.
You asked the Plan to pay for the dental service. You say that you disagree with the denial. You also say that
you feel it was an emergency visit due to the swelling of your gums. The Plan denied your request. The Plan
says consultation is not listed as a covered service. The Plan also says that any services not listed 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 consultation is not among those
covered under this benefit. The Evidence of Coverage clearly states that any services not listed are not covered.
Therefore, we decided that the Plan does not have to pay for the consultation (D9310) provided on March 10,
2021.