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

We decided that the Plan does not have to pre-approve the ophthalmology services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the ophthalmology services. You say that you would like the Plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent
nor urgent to seek out-of-network care. The Plan states there are equally qualified in-network ophthalmologists
available that can provide the care and treatment you are requesting
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
the ophthalmology services to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 8, 2019
You asked the Plan to pay for the physician services. You say that the facility requested the medically necessary service. The Plan denied your request. The Plan says services from non-participating providers are not covered under open access unless preauthorized.
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 November 8, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve replacement dentures.You asked the Plan to pre-approve the replacement dentures. You say that you misplaced your denture during a psychotic episode. You also say that you are unable to pay for a new denture because of your low income.The Plan denied your request. The Plan says that your dentures are less than 60 months old. The Plan also says that the service is not medically necessary.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. The Plan covers the replacement dentures when the services are medically necessary and reasonable. 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 replacement dentures. Our reviewer says that the service is not medically necessary. Our physician reviewer found you gave away your denture during one of your psychotic episodes that you suffer from. Our reviewer found that the denture was provided within the past 60 months and therefore would not be eligible for a replacement denture. Our physician reviewer found that the Plan provisions do not provide for extenuating circumstances to allow for earlier replacement. Our reviewer also found that due to the Plan limitations, and lack of any stated exceptions, the request for replacement dentures would not be medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the replacement dentures have not been met.Therefore, we decided that the Plan does not have to pre-approve replacement dentures.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe 5 additional periapical x-rays (D0230) provided on June 17, 2019.You asked the Plan to pay forthe 5 additional periapical x-rays. You say that a plan representative advised that the dentist was in network. You also say that you received a bill saying that the services are not covered because the dentist is not in network.The Plan denied your request. The Plan says the frequency limit has been exceeded. The Plan also says that 1 periapical x-ray per calendar year is 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 and periapical x-rays are a covered service, the frequency limit has been exceeded.Therefore, we decided that the Plan does not have to pay forthe 5 additional periapical x-rays (D0230) provided on June 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on September 19, 2019.
You asked the Plan to waive the copayment for the breast ultrasound. You say that you have never paid in the past for ultrasounds and mammograms. You say you had this done 6 months ago and did not have to pay 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 $250 copayment per day for Medicare-covered diagnostic radiology services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the ultrasound.
You have been asked to pay a $75.55 copayment for the breast ultrasound. The breast ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows this service was 100% covered on March 18, 2019.
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 breast ultrasound provided on September 19, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 10, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that you were informed the transport was covered because it was an emergency. You say that you could not have known there would be a copayment.The Plan denied your request. The Plan says the copayment 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 $300 copayment for each Medicare-covered trip (one-way).You have been asked to pay a $300 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 ambulance transport provided on September 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health podiatry services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve home health podiatry services. You say that the enrollee needs at home services. The Plan denied your request. The Plan says there are in-network at home health services available.
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 home health podiatry services to be provided 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 non-invasive ventilator (E0466).
You asked the Plan to pre-approve the ventilator. You say that this is the most effective treatment in order to effectively decrease work of breathing, improve pulmonary status and prevent interruption of respiratory support. The Plan denied your request. The Plan says medical necessity criteria have not been met.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 ventilator. Our reviewer says that the service is not medically necessary. Our physician reviewer found the enrollee is noted to have bronchodilator responsive, obstructive lung disease. There is no evidence that the enrollee has a restrictive thoracic disease or neuromuscular disease. An ABG has not been submitted for review. There is no evidence that the enrollee has ever before used BiPAP/CPAP or that such therapy was ineffective. As such, the documentation does not support that the use of a non-invasive ventilator is currently medically necessary or reasonable. 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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a non-invasive ventilator (E0466).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says medical studies have not proven that this drug is helpful for treatment of this health problem.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the submitted documentation, Medicare guidelines, and Medicare approved compendia were considered. Submitted diagnoses for the enrollee include monoclonall gammopathy and non-familial hypogammaglobulinemia. Medicare compendia do not support the use of Rituxan for these diagnoses. Medical necessity cannot be determined.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 drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Rituxan for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe cleaning (D1110) provided October 22, 2019.You asked the Plan to pay forthe dental service. You say that prior to visiting this provider you requested that they research your dental coverage. It was not until after the teeth cleaning the claim was denied because they were not in network.The Plan denied your request. The Plan says covered dental services must be provided by a network 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. The health plan contract specifically says that you must use a dentist in the dental network.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 forthe cleaning (D1110) provided October 22, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not require transfer to the LTACH.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH following emergency surgery for a perforated ulcer. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe crown (D2740) and core build up (D2950) provided on December 10, 2019.You asked the Plan to pay forthe dental services. You say that the $100 dental reimbursement is not enough to assist with the services that you received. You also say that $100 is not enough to pay for dental care in general.The Plan denied your request. The Plan says your $100 dental reimbursement has already been exhausted for 2019.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  $100 reimbursement for dental services has been exhausted for 2019.Therefore, we decided that the Plan does not have to pay forthe crown (D2740) and core build up (D2950) provided on December 10, 2019.
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 to have the approved for an office visit.The Plan denied your request. The Plan says you have been approved to see two different physicians. 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 topical application of fluoride varnish (D1206) provided November 21, 2019.You asked the Plan to pay for the fluoride varnish. You say that you was never notified this procedure was no longer covered after you cancelled the extra dental plan. You should have been notified of what was not covered.The Plan denied your request. The Plan says this service is not a covered benefit.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. The health plan contract says that any service not listed under the Description of Benefits is not covered by the plan.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 topical application of fluoride varnish (D1206) provided November 21, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve endovenous ablation therapy. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained 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 endovenous ablation therapy to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.You asked the Plan to pre-approve the referral. You say that your wife cannot drive you to the in-network providers.The Plan denied your request. The Plan says there is no evidence that you are unable to utilize other methods of transportation, such as that provided by 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 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 a referral to an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approve the LTACH services. You say that you feel that this treatment is medically necessary.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found The patient is currently undergoing treatment at an ACH for respiratory failure in the setting of an esophageal leak following recent paraesophageal hernia surgery. The enrollee received a tracheotomy and was on a ventilator following her surgery. The esophageal leak has not been ameliorated and the enrollee has not been amenable to ventilator weaning. It would appear that weaning will not be possible until the leak is fixed or resolves. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services