Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit and laboratory services (G0463, 85027, 83735, 80069, 80197) provided on April 6, 2020 by an out of network (OON) provider. You asked the Plan to pay for the hospital outpatient clinic visit and laboratory services. You say that you were not aware prior authorization was required. The Plan denied your request. The Plan says prior authorization was not obtained by the facility or the provider; therefore, payment has been correctly denied. 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 hospital outpatient clinic visit and laboratory services (G0463, 85027, 83735, 80069, 80197) provided on April 6, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.

You asked the Plan to pre-approve SNF admission. You say that the enrollee needs further care and therapy. The Plan denied your request. The Plan says SNF admission is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found although the member is making slow progress with therapy, there is no indication that transfer to a skilled nursing facility is required. There are no services offered at a SNF that are not offered at an inpatient rehab facility. Admission to a SNF for inpatient skilled rehab services 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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve walk-in shower.You asked the Plan to pre-approve walk-in shower. You say that a walk-in shower is medically necessary.The Plan denied your request. The Plan says walk in showers are not covered by the Plan or by Medicare.The Plan must follow Medicare rules.



 Medicare does not cover shower or bath equipment. While a walk-in shower may be beneficial for your use, this type of equipment is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve walk-in shower
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided by a participating provider on February 10, 2020.
You asked the Plan to waive the copayment for physical therapy. You say that you do not agree with this copayment. 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 $25 copayment for outpatient rehabilitation services/in-network/physical therapy. You have been asked to pay a $25 copayment for physical therapy. Physical therapy falls within the outpatient rehabilitation services/in-network/physical therapy 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 by a participating provider on February 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have topay forthe laboratory services (87640, 87581, 87541 and 87486) provided on April 1, 2020 by an out of network (OON) provider.You asked the Plan to pay forlaboratory services. You say that you do not see the patient directly, you provide medically necessary services on specimen sent to you by another provider.The Plan denied your request. The Plan says prior authorization must be obtained for non-emergent services rendered by an out-of-network provider.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 forthe laboratory services (87640, 87581, 87541 and 87486) provided on April 1, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for insertion of a new or replacement of permanent pacemaker with transvenous electrode (33208).
You asked the Plan to waive the coinsurance for outpatient surgery. You say that you disagree with the coinsurance. The Plan denied your request. The Plan says the coinsurance is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 25% coinsurance for Outpatient surgery, including services provided at hospital outpatient. You have been asked to pay a 25% coinsurance for outpatient surgery. This service falls within the Outpatient surgery, including 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 coinsurance for insertion of a new or replacement of permanent pacemaker with transvenous electrode (33208).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay the full amount for the oral exam (D0120), prophylaxis (D1110), and the complete series of x-rays (D0210) provided on June 22, 2020.
You asked the Plan to pay the full amount for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says that the dentist in this case is not a network provider. The Plan says that for covered services, you may still be billed by an out-of-network provider for any amount greater than the MAC payment made by the plan to the provider.
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, you may be billed more for services that you received out-of-network. The record shows that the Plan paid the full allowed amount. Therefore, we decided that the Plan does not have to pay more for the oral exam (D0120), prophylaxis (D1110), and the complete series of x-rays (D0210) provided on June 22, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 2D oral or facial photographic image (D0350) and the unspecified preventive procedure (D1999) provided on June 30, 2020.You asked the Plan to pay forthe dental services. You say that you did not know that you would have to pay a sanitary protection fee before your consultation. You say that you were under the impression that all of the services would be covered. You also say that you were not aware that you would have to pay for the x-rays.The Plan denied your request. The Plan says the 2D oral or facial photographic image is not listed as a covered service. The Plan says the unspecified preventive procedure is not listed as a covered service. The Plan also says dental services that are 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 requested items or services are 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 forthe 2D oral or facial photographic image (D0350) and the unspecified preventive procedure (D1999) provided on June 30, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on June 1, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that you misunderstood and thought you didn't have a copayment for CT scans. The Plan denied your request. The Plan says you were charged this copayment 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 $150 copayment for diagnostic radiology services. You have been asked to pay a $150 copayment for the CT scan. The CT scan falls within the diagnostic radiology services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan you had on June 1, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on June 29, 2020.
You asked the Plan to waive the copayment for arthrocentesis. You say that you paid $48.34 and disagree with the additional charges. 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 $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $250 copayment for arthrocentesis. Arthrocentesis falls within the outpatient surgery, including 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 arthrocentesis provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve chiropractic services. You say that you would like prior authorization for these services. The Plan denied your request. The Plan says there are multiple 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 chiropractic services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveXiidra ophthalmic solution.You asked the Plan to pre-approveXiidra eye drops. You say that you want the enrollee treated with this drug.The Plan denied your request. The Plan says this drug 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-approveXiidra ophthalmic solution.Benefits for Xiidra eye dropsmay be available under MedicarePart D. Contactthe 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 crown (D2740) and core build up (D2950) provided on July 27, 2020.
You asked the Plan to pay for the dental services. You say that this service was covered by your policy in 2019. You say that you do not remember receiving a notice that the procedure was no longer covered. You say that you are retired and on a fixed income. You also say that you would like at least part of the expense to be covered. The Plan denied your request. The Plan says the crown is not listed as a covered service. The Plan says that core build up is not listed as a covered service either. The Plan also says 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 requested items or services are not among those covered under this benefit. Additionally, the record shows that an Annual Notice of Change in Benefits was mailed on October 17, 2019. Therefore, we decided that the Plan does not have to pay for the crown (D2740) and core build up (D2950) provided on July 27, 2020.
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. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is 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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has arthritis of knees, hips and back. The patient lives at home and is having increasing problems with ambulation. Medical problems are stable. There are no identified problems that need inpatient medical management. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The medical record supports a need for physical and occupational therapy but it does not support a need for an intensive rehabilitation therapy program. There is not a reasonable expectation that this patient 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 IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that a shower chair is medically necessary.The Plan denied your request. The Plan says Medicare does not cover shower chairs.The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.Therefore,we decided that the Plan does not have to pre-approvea shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the pontics and retainer crown for a bridge provided on July 16, 2020.
You asked the Plan to pay for the pontics and retainer crown for a bridge. You say that you didn't find anything that said bridges would not be paid for, so you received the bridge. You say that insurance has always covered your needs. The Plan denied your request. The Plan says the services are not covered benefits.
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 pontics and retainer crown for a bridge provided on July 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $300 copayment charged for an ambulance transport
provided on July 9, 2020.
You asked the Plan to waive this copayment. You say that you do not be believe this copayment should be
charged. The Plan denied your request. The Plan says this copayment was charged based on the service
provided and the Plan contract agreement.
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 $300
copayment for ambulance transport.
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 $300 copayment charged for an ambulance transport provided on July 9, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea therapeutic continuous glucose monitor (CGM).You asked the Plan to pre-approvethese services. You say that the services should be covered.The Plan denied your request. The Plan says you do not meet the criteria for coverage.The Plan must follow Medicare rules. Medicare rules say that a therapeutic CGM is covered when specific criteria are met.We looked at the file and Medicare rules. The records show that you do not perform frequent blood sugar checks of four or more times per day. 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-approvea therapeutic continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forfacet joint injections (64495) provided May 5, 2020.You asked the Plan to pay forthe injection services. You say that Medical records request was not received however, your clearinghouse called to check on the status of the claim and were advised that additional medical records were needed.The Plan denied your request. The Plan says the records do not support service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 64495 is njection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral. 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 injection services. Our reviewer says that the records do not support the Medicare coverage criteria. Our physician reviewer found the procedure report documents an injection was performed on 2 levels, therefore, a 3rd level cannot be verified.  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 injection services have not been met.Therefore, we decided that the Plan does not have to pay forfacet joint injections (64495) providedMay 5, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the lab services provided to you on September 25, 2019.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says that this service is
not covered.
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.
You were provided the lab services by a contract provider. The file does not show that the Plan provided notice
that the lab services would not be covered. Under Medicare rules, this means the lab services is considered
approved by the Plan. You received the services with the reasonable expectation that the services would be
covered. Therefore, we decided that the Plan has to pay for the lab services provided to you on September 25,
2019.