Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a suction toothbrush kit.
You asked the Plan to pre-approve a suction toothbrush kit. You say that the enrollee needs a suction toothbrush to provide additional care and protections for dental needs. The Plan denied your request. The Plan says this device is primarily hygienic in nature and does not serve a primarily medical purpose.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a suction toothbrush kit.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 12, 2018.
You asked the Plan to pay for the ambulance services. You say that the claim was submitted timely to the wrong payer. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the ambulance services was not filed until October 19, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on October 12, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit and pulmonary testing provided on November 4, 2019.
You asked the Plan to waive the copayment for the office visit and pulmonary testing. You say that you already paid $40 for the office visit. You say that you did not agree to a separate charge. The Plan denied your request. The Plan says the copayments 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 $40 copayment per specialist visit and a $40 copayment per provider, per date of service for diagnostic services. You have been asked to pay a $40 copayment for the office visit and a $40 copayment for the pulmonary testing. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The pulmonary testing 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 the office visit and pulmonary testing provided on November 4, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the PCP office visit you had on September 20, 2019.
You asked the Plan to waive the visit. The Plan denied your request. The Plan says that a decision was not made within the time frame.
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 each primary care doctor visit. The records show that you had a PCP visit on September 20, 2019. The Plan says you must pay a $30 copayment for the visit. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for the visit. Therefore, we decided that the Plan has to waive the copayment for the PCP office visit you had on September 20, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.
You asked the Plan to pre-approve these services. You say that you need the testing to alleviate issues with breathing and sleeping. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a sleep study is covered when specific criteria are met.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the records show that you have daytime
sleepiness and there is a suspicion for obstructive sleep apnea. The Plan has approved a sleep study with PAP
titration described by procedure code 95811 and this is an appropriate study. The requested sleep study
described by code 95810 would duplicate the approved test and is not medically 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 these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve a sleep study.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician's services provided on June 17, 2019.
You asked the Plan to pay for the physician's services. You say that while you were on vacation, out of the Plan's service area, you went to an urgent care facility due to your ear bleeding and the urgent care provider referred you to see an otolaryngologist. You say that you called the Plan prior to the office visit to let them know and to receive authorization for the office visit. You say that you followed the instructions on your insurance card, and you should be covered for the services. The Plan denied your request. The Plan says that the provider is not in-network.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis, and pre-approved care. 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 physician's services. Our reviewer says that the physician's services are medically reasonable and necessary. Our physician reviewer found that you could not have foreseen requiring the services of an ENT prior to leaving your service area. The injury occurred after you had already left the service area. The medical records indicate that the care provided was medically necessary. Given the fact that your ear was bleeding, it would not have been medically reasonable to delay the services until you returned to your service area. You were advised by an urgent care provider to see an ENT in the area for your condition. Bleeding from anywhere in the head and neck region should always be evaluated and managed as expeditiously as possible. Bleeding from the ear can be a symptom of a more serious condition and should not be delayed because the enrollee is not in the service area.
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 physician's services have been met. Therefore, we decided that the Plan has to pay for physician's services provided on June 17, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclopentolate 1% eye drops.
You asked the Plan to pre-approve the eye drops. You say that this is medically necessary. The Plan denied your request. The Plan says this is a drug that you apply yourself.
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 Cyclopentolate 1% eye drops.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the room and board for long term care hospice provided from March 23, 2017 through March 28, 2017.
You asked the Plan to pay for the room and board for long term care hospice. You say that room and board is not a covered service by Medicare. You say that this is a covered service by the Plan. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the room and board for long term care hospice provided from March 23, 2017 through March 28, 2017.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on July 24, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that you feel that you are being overcharged for polyp removal. 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 $195 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you had polyps removed during a colonoscopy on July 24, 2019. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $195 copayment. You have been asked to pay a $195 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery and other medical 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 a colonoscopy provided on July 24, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation and limited problem focused re-evaluation provided on January 18, 2019 and February 1, 2019.
You asked the Plan to pay for the bone replacement graft and re-evaluation. You say that the dental work was necessary because you were in pain which made it uneasy for you to eat or sleep. The Plan denied your request. The Plan says these services are not covered under your contract under any normal circumstances.
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 bone replacement graft for ridge preservation and limited problem focused re-evaluation provided on January 18, 2019 and February 1, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit on September 26, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you were admitted to the hospital and should not be charged a copayment. 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 emergency care. The medical records show that you were admitted under observation following an ER visit on September 26, 2019. An observation stay is not considered an inpatient hospital admission. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for an ER visit. An ER visit falls within the emergency care 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 ER visit on September 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on October 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You called on October 14, 2019 and were advised that the provider is participating with the member's plan. You believe the claim was denied by mistake. The Plan denied your request. The Plan says while the member is a part of the plan, they must use network providers to get their medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when the member is out of the area), out-of-area dialysis services and cases in which the plan authorizes use of out-of-network providers. After review, it was determined that procedure code 99214 is not covered by the health plan, because the provider is outside of the member's network of providers and prior authorization was not obtained from the plan. Additional review also determined that the claim does not meet the urgent or emergent criteria based on the procedure code and diagnosis code submitted.
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. A thorough search was conducted on the provider. No name was found in the Plan's listing of participating providers. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on October 2, 2019 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc for the enrollee.
You asked the Plan to pre-approve Genvisc. You say that the enrollee's quality of life is in danger as he cannot walk. The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Genvisc. Our physician reviewer found that the enrollee has bilateral primary osteoarthritis of the knees. The plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. There is not documentation that Monovisc and Orthovisc have been tried and failed. The documentation does not support that Monovisc and Orthovisc would likely be less effective, or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acute inpatient hospital care provided from July 30, 2019 to August 3, 2019.
You asked the Plan to waive the copayment. You say that you were dissatisfied by the services you received
from the facility. The Plan denied your request. The plan says there is a $295.00 copayment
each day for days 1 to 5 for Medicare-covered inpatient hospital care. The Plan says a copayment will be
applied each time you are admitted to the hospital. The copayment was correctly applied to the inpatient
hospital care. Cost shares are a contractual obligation of the plan and cannot be waived.
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 each day for days 1 to 5 for Medicare-covered hospital care. There is a $0 copayment for additional
Medicare-covered days.
You have been asked to pay a $1,180 copayment for inpatient hospital care ($295 x 4 days). 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 acute inpatient hospital care provided July 30, 2019 to August 3,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve out-of-area urology services.
You asked the Plan to pre-approve the out-of-area services. You say that you need to see a urologist for an elevated PSA level. The Plan denied your request. The Plan says care is available in-network.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. 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 out-of-area services. Our physician reviewer found that you had lab work ordered by your primary provider, revealing an elevated prostate specific antigen (PSA) level. You are out of the area for several months and sought care from a urologist in follow-up to the abnormal laboratory level. The services are not considered emergent. A pre-authorization request or consultation with an in-network could have been sought. Therefore, the requested out-of-area services are not 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 out-of-area services have not been met. Therefore, we decided that the Plan does not have to pre-approve out-of-area urology 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 an IRF program would make you work harder and allow you to get home quicker. The Plan denied your request. The Plan says you could be treated 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 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional physical and occupational therapy, but you do not require this on an intensive rehabilitation facility therapy program level 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the BRCA genetic testing rendered to the enrollee on September 6, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the testing is not covered.
The Plan must follow Medicare rules. The rules say that BRCA1 and BRCA2 genetic testing is considered medically necessary for a beneficiary with a current diagnosis or a personal history of a cancer associated with the BRCA mutation. We looked at the file and Medicare rules. The file shows that the enrollee did not have a personal history of cancer associated with the BRCA mutation. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the BRCA genetic testing rendered to the enrollee on September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a crown and core build up for tooth 5.
You asked the Plan to pre-approve these services. You say that the tooth is cracked and is causing pain. The Plan denied your request. The Plan says the services 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 requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a crown and core build up for tooth 5.