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

We decided that the Plan does not have to pre-approve an exception to the 60 mile limit for routine
transportation.
You asked the Plan to pre-approve exceptions to supplemental benefits. The Plan denied your request. The Plan
says that request for trips over the 60 mile limit are denied.
Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we
decided that the Plan does not have to pre-approve an exception to the 60 mile limit for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (99212, 98943, 98941) provided on August 8, 2019 to August 15, 2019 by an out of network (OON) provider.
You asked the Plan to pay for OON chiropractic services. You say that you did not know this provider was OON. The Plan denied your request. The Plan says these services were not authorized.
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 chiropractic services (99212, 98943, 98941) provided on August 8, 2019 to August 15, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two more bilateral transforaminal epidural injection(s), of diagnostic or therapeutic substance. You asked the Plan to pre-approve the remaining two epidural injections (62323). You say that the enrollee did get relief from the last injection but needs a series of 3, two weeks apart. The Plan denied your request. The Plan says the medical necessity for upfront approval of 3 bilateral Epidural steroid injections is not established. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the remaining two epidural injections have not been met. Therefore, we decided that the Plan does not have to pre-approve two more bilateral transforaminal epidural injection(s), of diagnostic or therapeutic substance
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on January 20, 2020.
You asked the Plan to pay for the periodontal maintenance. You say that you do not understand why the amount of money that would be allotted for a regular cleaning cannot be approved and put toward the cost of a special cleaning that is necessary for some people. The Plan denied your request. The Plan says this service is not a covered benefit under your insurance 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. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on January 20, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a physical therapist on December 26, 2019.You asked the Plan to waive the copayment for outpatient rehabilitation. You say that you were never asked for a copayment. You say that you did not know you owed anything until you received a bill. The Plan denied your request. The Plan says the correct copayment has been 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 a $40 copayment for outpatient rehabilitation services/in-network. You have been asked to pay a $40 copayment for outpatient rehabilitation. Outpatient rehabilitation falls within the outpatient rehabilitation services/in-network 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 physical therapy provided bya physical therapist on December 26, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the eye exam provided on December 10,
2019.
You asked the Plan to waive the deductible for the eye exam. The Plan denied your request. The Plan says that
you are responsible for the deductible.
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 there is a $1,000 deductible for Non-Medicare covered Routine eye exams.
The item or service you asked the Plan to waive the deductible for falls within the benefit category of Non-
Medicare covered Routine eye exams. The Plan has followed Medicare rules by clearly disclosing in the
contract that there is a $1,000 deductible for Non-Medicare covered Routine eye exams. This cost sharing is a
contractual obligation that had not been met at the time the eye exam was received on December 10, 2019.
Therefore, we decided that the Plan does not have to waive the deductible for the eye exam provided on
December 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 27, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that 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. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on November 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provided on August 22, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not approved in advance.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 payfor 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 forthe medical services provided to the enrollee by an out-of-network provided on August 22, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from August 21, 2019 to August 26, 2019.
You asked the Plan to pay for the home health 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 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 home health services provided from August 21, 2019 to August 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis providedon December 3, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met.Therefore, we decided that the Plan does not have to pay forthe lumbar-sacral orthosis providedon December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are available in-network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 to the enrollee by an out-of-network provider on September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 26, 2019.
You asked the Plan to pay for the lumbar-sacral orthosis (L0650). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis (L0650) have not been met. Therefore, we decided that the Plan does not have to pay for the lumbar-sacral orthosis provided on November 26, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe air ambulance services provided on October 7, 2019.You asked the Plan to pay forthe air ambulance 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 as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We looked at the file and Medicare rules. The file shows the claim was billed with primary diagnosis code I50.3. Per Medicare guidelines, providers must bill to the highest level of specificity. Medicare says a three-character diagnosis code is to be used only if it is not further subdivided. I50.3 can be further subdivided and is not payable in this case.Therefore, we decided that the Plan does not have to pay forthe air ambulance services provided on October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on January 8, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The PlansaysHealthcare Common Procedure Coding System (HCPCS) G0483 remains not supported.The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered.The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plandoes not haveto pay fordrug testing services provided to the enrollee on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveurology treatment to be provided at the tertiary level of care.You asked the Plan to pre-approveurology services. You say that you are confident in this provider and want to see him.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because you do not need treatment at the tertiary level of care and can be treated by a community level provider.Medicare rules generally allow plans to restrict enrollees to using plan providers as long asthere are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for 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 urology services. Our reviewer says that you do not meet the criteria for treatment at the tertiary level of care. Our physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet your needs through referral to a community level urology specialist. There is not anything unique about your condition that would make it medically necessary for you to see the requested tertiary level of care provider. The Plan has shown that they have community level providers who meet the standards of care required for treatment of your condition. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of urology services have not been met. Therefore, we decided that the Plan does not have to pre-approveurology treatment to be provided at the tertiary level of care
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), the panoramic x-ray (D0330), the full mouth debridement (D4355), and the bitewing x-rays (D0274) provided from September 18, 2019 to October 2, 2019 by the out of network provider.You asked the Plan to pay forthe dental services. You say that the provider has been in network for as long as you can remember. You say that you were advised by the enrollee's plan that there are no provider's in your location that were contracted with them. You also say that the provider is now credentialed.The Plan denied your request. The Plan says the provider in this case was not a network provider at the time the services were rendered to the enrollee. The Plan also says that services performed 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, dental services performed out of network are not covered.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation (D0150), the panoramic x-ray (D0330), the full mouth debridement (D4355), and the bitewing x-rays (D0274) provided from September 18, 2019 to October 2, 2019 by the out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuation of skilled nursing facility (SNF) care.You asked the Plan to pre-approvethe continuationof SNF care. You say that you need continued wound care and should remain in the SNF.The Plan denied your request. The Plan says the 100 day SNF benefit has been exhausted and the services being requested are not covered.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from January 15 through April 24, 2020. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row.Therefore, we decided that the Plan does not have to pre-approvea continuation of skilled nursing facility (SNF) care.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve wheelchair van transport for the enrollee.
You asked the Plan to pre-approve wheelchair van transport. The Plan denied your request. The Plan says that no information was provided to show that the enrollee cannot travel via a standard van or car.
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 wheelchair van transportation when the above criteria have been met. We asked our physician reviewer to carefully review the case file and apply the relevant Plan rules to determine if the Plan was correct in denying the request for wheelchair van transport. Our reviewer says that wheelchair van transport is not medically reasonable and necessary for the enrollee in this case. The health plan reports that the enrollee is able to ambulate, but has not submitted documentation to support this claim. The provider record indicates that the enrollee uses a wheelchair, but does not note that the enrollee is wheelchair bound or that the enrollee is non-ambulatory. A diagnosis of post-herpetic nervous system involvement does not in-and-of-itself support a need for transportation. Our physician reviewer found the documentation is insufficient to show that the enrollee meets the criteria for transport via a wheelchair van. We looked at the physician's review, the file and the rules. Based on this information, we decided that the Plan's rules for coverage of wheelchair van transportation have not been met. Therefore, we decided that the Plan does not have to pre-approve wheelchair van transport for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on September 25, 2019.You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says that the therapeutic exercises provided by the chiropractor are not a covered benefit under the enrollee's contractual policy.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 servicesat issue arenot manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe therapeutic exercises (97110) provided on September 25, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy provided on October 14, 2019 by an out of network (OON) provider.You asked the Plan to pay for physical therapy. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.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 physical therapy provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the catheter and lubricant provided on January 17, 2020.
You asked the Plan to waive the coinsurance for the catheter and lubricant. You say that you were never notified of a change in cost. You say that you shouldn't owe this amount. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for prosthetic devices and medical supplies. You have been asked to pay a total of $52.16 for the catheter and lubricant. The catheter and lubricant fall within the "Prosthetic devices 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 the catheter and lubricant provided on January 17, 2020.