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

We decided that the Plan has to pay for emergency services provided to the enrollee on November 21, 2019.You asked the Planto pay for the services. You say that the services were medically necessary.The Plan denied your request. The Plan says that they did not render a decision in the allotted time frame.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 did not substantiate their denial, as no medical records from the emergency visit were provided.Therefore, we decided that the Plan has to pay for emergency services provided to the enrollee on November 21, 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: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for physician observation care services provided on August 20, 2019.You asked the Plan to pay for the physician observation care services. The Plan denied your request. The Plan says that the provider is not in-network and there is no authorization on file.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.The physician observation care services were provided in a contracted facility for which this physician is affiliated. The file does not show that the Plan provided notice that the physician observation care services would not be covered prior to the services being rendered. Under Medicare rules, this means the physician observation care services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for physician observation care services provided on August 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you would like approval for these services. The Plan denied your request. The Plan says there are in-network providers available for these services.
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 an office visit to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture, complete mandibular denture, and repair of broken complete maxillary denture base provided by an OON dentist on January 6, 2020.
You asked the Plan to pay for the complete maxillary and mandibular dentures and repair of broken complete maxillary denture base. You say that you contacted the Plan multiple times and were always told that dentures are covered. You also say that you were never informed that prior authorization was required. The Plan denied your request. The Plan says services are only covered by the enrollee's Health Plan for in network dentists. The Plan also says that the records do not show that the enrollee's dentist is in the Plan's provider network.
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. The Plan also says that the enrollee contacted the Plan on January 2, 2019 and was informed that their benefit plan did not offer any coverage for dentures. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture, complete mandibular denture, and repair of broken complete maxillary denture base provided by an OON dentist on January 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 6, 2020 by a non-network provider.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 services were rendered by a non-network provider without 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 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 medical services provided on January 6, 2020 by a non-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 30, 2020.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says services rendered by non-participating 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 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 lab services provided to the enrollee on January 30, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from December 30, 2018 to January 9, 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 claim was not billed correctly.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis code. We looked at the file and Medicare rules. The file shows that the claim was billed with an invalid diagnosis code. 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 inpatient hospital services rendered from December 30, 2018 to January 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on January 29, 2020.You asked the Plan to waive the copayment fora specialist visit. You say that you disagree with the charges because you had an appointment to see the specialist but only saw a nurse.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 visits. You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on January 29, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has bilateral primary osteoarthritis of the knees. She has not tried and failed the Plan's required drugs of Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Euflexxa is not reasonable or medically necessary at this time.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 Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveincontinence supplies.You asked the Plan to pre-approveincontinence supplies. You say that incontinence supplies are necessary because of the enrollee's medical condition.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.Therefore, we decided that the Plan does not have to pre-approveincontinence supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the arthrocentesis, the Part B injection and the chemotherapy injection provided on September 12, 2019 to October 1, 2019.
You asked the Plan to waive the cost share for the specialist office visit and the chemotherapy injection. You say that you do not agree with the cost share amount for the office visit and the injection. You say you were told that everything was covered. 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 $15 copayment for specialist visits and 20% of the cost for Part B drugs such as chemotherapy drugs and other Part B drugs. You have been asked to pay a total of $341.54 for the arthrocentesis, the Part B injection, and the chemotherapy injection. The arthrocentesis falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Part B injection and the chemotherapy injection falls within the "Medicare Part B prescription drugs" benefit category.
Dates of Service
Service
Allowed Amount
Coinsurance/Copayment
Member Liability
September 12, 2019
Arthrocentesis
$207.63
$15.00
$15.00
September 12, 2019
Part B injection
$12.72
20%
$2.54
October 1, 2019
Chemotherapy injection
$1,620.00
20%
$324.00
Total
$341.54
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 cost share for the arthrocentesis, the Part B injection and the chemotherapy injection on September 12, 2019 to October 1, 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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 required minimal to moderate assistance with most activities of daily living. The enrollee was able to walk 10 feet times four with a rolling walker. The documentation does not support that the complexity of the enrollee's nursing, medical and rehabilitation needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the enrollee would benefit from further physical therapy and occupational therapy, the enrollee does not require treatment in an intensive rehabilitation 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids.
You asked the Plan to pre-approve hearing aids. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pre-approve hearing aids.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery provided on June 14, 2019 through September 15, 2019.
You asked the Plan to pay for the cataract surgery. You say that you would like reconsideration because these services were medically necessary. The Plan denied your request. The Plan says worldwide coverage requires that the services be emergent or urgently needed.
The Plan must follow Medicare rules. Medicare rules say that services received outside of the United States are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cataract surgery have not been met. Specifically, the Plan covers services rendered outside of the United States when the services are urgent or emergent. The record does not indicate that the cataract surgery was urgent or emergent. Therefore, we decided that the Plan does not have to pay for cataract surgery provided on June 14, 2019 through September 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and panoramic jaw imaging provided on November 19, 2019.You asked the Plan to pay for the evaluation and jaw imaging. You say that it is felt that these services were medical in nature and should be paid.The Plan denied your request. The Plan says Medicare only covers follow-ups related to an oral appliance for sleep apnea for 90 days after the appliance is made. Please note that the Plan appears to have misinterpreted coverage provisions in its rationale. There is no regulation which would prevent payment for exams related to this device if the exam were reasonable and necessary for treatment of a medical condition.The Plan must follow Medicare rules. Medicare rules say that only services that are reasonable and necessary for the treatment or diagnosis of a medical condition may be covered. Medicare does not cover services for the care or treatment of teeth or supporting structures of the teeth.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 evaluation and jaw imaging. Our reviewer says that the services provided in this case are not considered medically reasonable and necessary for the diagnosis or treatment of a medical condition. Our physician reviewer found the documentation supplied appears to be directed at evaluating the dental structures following use of the oral appliance. The teeth, occlusion and TMJ were evaluated. It does not support that the evaluation was reasonable and medically necessary to treat a medical condition and no current medical condition was identified to be treated. It was indicated the visit was for OSA second year exam. The radiographic examination was not performed to treat a medical condition. It was performed to assess overall structures of the jaws, looking at the TMJ, as well as reviewing sinuses and occlusion to some extent to assess possible adverse effects of appliance on the oral structures. It was not for evaluating any medical issues such as airway issues. 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 evaluation and jaw imaging have not been met.Therefore, we decided that the Plan does not have to pay for the evaluation and panoramic jaw imaging provided on November 19, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 23, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that the facility failed to obtain necessary authorization for this enrollee.The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. 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 the medical services provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee walker (E0118).
You asked the Plan to pre-approve the knee walker. You say that the knee walker is medically necessary. The Plan denied your request. The Plan says knee walkers are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare has determined that crutch substitutes such as knee walkers are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee walker. have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee walker (E0118).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of sacroiliac joint nerves (64625).
You asked the Plan to pre-approve radiofrequency ablation of sacroiliac joint nerves. You say that this service has helped you in the past. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve radiofrequency ablation of sacroiliac joint nerves. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental/ investigational procedure because of the wide variation in efficacy in the peer reviewed literature. Therefore, the request is considered 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 radiofrequency ablation of sacroiliac joint nerves have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of sacroiliac joint nerves (64625).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110) provided on June 6, 2019 by an out of network dentist.
You asked the Plan to pay for the dental services. You say that the dental services that the enrollee received are basic coverage that should be afforded to the enrollee. You say that there is not a network provided in the enrollee's area. You also say at what would have been covered for a PPO plan would be expected. The Plan denied your request. The Plan says the provider in this case is not a network provider. The Plan says that dental services that you receive out of network are not covered. The Plan also says there are in network dentists in the enrollee's service area.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, dental services are not covered under this benefit when you receive them out of network. Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110) provided on June 6, 2019 by an out of network dentist.