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

We decided that the Plan does not have to pay for the hormone treatment services provided June 30, 2021.
You asked the Plan to pay for the hormone treatment services. You say that the labs were necessary to determine appropriate hormone treatment due to your chemo-induced menopause. The Plan denied your request. The Plan says the services were obtained from a provider that is not certified for Medicare. If you go to a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care. The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the hormone treatment services provided June 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on November 18, 2020.
You asked the Plan to waive the copayment for the ambulance services. You say that Medicare should have paid 80% of this charge, but you are being billed $250. The Plan denied your request. The Plan says under your Plan, you have a $250 copayment for this service.
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 ambulance services. You have been asked to pay a $250 copayment for the ambulance services. 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 ambulance services provided on November 18, 2020
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on August 15, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you cannot afford this copayment. 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 $295 copayment for ambulance services.
You have been asked to pay a $295 copayment for the ambulance services. 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 ambulance services you received on August 15, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more toward the limited oral evaluation (D0140), intraoral x-ray (D0220), prefabricated post and core (D2954) and endodontic therapy (D3310) provided on July 14, 2021.
You asked the Plan to pay more toward the limited oral evaluation (D0140), intraoral x-ray (D0220), prefabricated post and core (D2954) and endodontic therapy (D3310). You say that you went to this doctor because they said they accept your insurance. You say that you would not have gone there if they didn't take your insurance and you should not be responsible for the dental work you had done. The Plan denied your request. The Plan says the claim processed correctly.
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 Plan is only obligated to pay the allowed amount for the intraoral x-ray (D0220), prefabricated post and core (D2954) and endodontic therapy (D3310) from an out-of-network provider. You will be billed for charges above what the plan pays to the out-of-network provider.
In addition, a limited oral evaluation is only covered once per plan year. The Plan paid for the limited oral evaluation provided on May 11, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more toward the limited oral evaluation (D0140), intraoral x-ray (D0220), prefabricated post and core (D2954) and endodontic therapy (D3310) provided on July 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 30 additional physical therapy visits.
You asked the Plan to pre-approve the 30 additional physical therapy visits. You say that you would like reconsideration because the additional physical therapy is medically necessary. The Plan denied your request. The Plan says 6 additional visits are appropriate, but the remaining 30 are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 30 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found you have had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist for 30 more therapy sessions. You have been authorized 6 of the requested 36 visits which appears appropriate for your level of dysfunction and deficits. 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 30 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 30 additional physical therapy visits.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided July 16, 221 to July 22, 2021.
You asked the Plan to pay for the inpatient services. You say that the enrollee was enrolled in hospice, however, was not admitted for hospice related treatment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on July 16, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient services provided July 16, 221 to July 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the neck you had on July 19, 2021.
You asked the Plan to waive the copayment for the CT scan. You say that you are on a fixed income and cannot afford this copayment. 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 $325 copayment for diagnostic radiology services. You have been asked to pay a $325 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 of the neck you had on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids provided on July 29, 2021.
You asked the Plan to pay for hearing aids. You say that you were not aware of your hearing aid benefit. The Plan denied your request. The Plan says hearing aids must be provided by the Plan's hearing provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file and the Plan's rules. The file shows that the hearing aids were not provided by the Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids provided on
July 29, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from October 25, 2020, to October 28, 2020.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you do not think you should have to pay the copayment because the enrollee wasn't able to take a shower and he did no have anything to eat for a day and a half. The Plan denied your request. The Plan says this copayment was charged 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $225 copayment per day for days 1-7 for inpatient hospital care.
Records show that the enrollee was in the hospital for three days. He was charged a $225 copayment per day, for a total of $675. This copayment applies regardless of your satisfaction with the services. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital services provided from October 25, 2020, to October 28, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for skilled nursing facility (SNF) services you received from June 1, 2021, to June 30, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you were not aware that there would be a cost for days 21-57. 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 $0 copayment for days 1-20, and a $184 copayment per day for days 21-57 for skilled nursing facility services.
Records show that you were in the SNF from May 25, 2021, to June 30, 2021, for a total of 37 days. You were not charged a copayment for the first 20 days. For the remaining 17 days, you were charged a $184 copayment per day, for a total of $3128. 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 skilled nursing facility (SNF) services you received from June 1, 2021, to June 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for transportation of portable x-ray equipment and personnel (R0070) set-up portable x-ray equipment (Q0092) radiologic examination, forearm, 2 views (73090) radiologic examination, shoulder (73030) and radiologic examination, scapula, complete (73010) provided on July 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the portable x-ray services. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 had network providers available who could have provided 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 transportation of portable x-ray equipment and personnel (R0070) set-up portable x-ray equipment (Q0092) radiologic examination, forearm, 2 views (73090) radiologic examination, shoulder (73030) and radiologic examination, scapula, complete (73010) provided on July 10, 2021 by an out-of-network (OON) provider
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided October 4, 2020 to October 7, 2020.
You asked the Plan to pay for the inpatient services. You say that say the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the inpatient services provided October 4, 2020 to October 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esbriet caplet 267mg 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 there are no pharmacy benefits administered by this plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Esbriet caplet 267mg for
the enrollee.
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 in-patient acute care and does not
require transfer to 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 there is no documentation provided indicating medical necessity for admission to a
LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where she is currently receiving
care. There are no services available at the LTACH that the enrollee requires that are not available at the health
care setting being offered by the health plan. The requested LTACH services are not medically necessary,
reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and
effectively only on an inpatient basis.
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 for the dental services provided by an out-of-network provider
on July 27, 2021.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says services
provided by an 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, out-of-network dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental
services provided by an out-of-network provider on July 27, 2021.
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 transfer to an LTACH is medically
necessary to fully improve the enrollee's condition and avoid unnecessary hospital re-admissions in the future.
The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's
needs are being met in the current acute care hospital. There is no documentation that the enrollee will benefit
from and improve with LTACH management.
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 that the short-term acute care hospital can provide for all of the enrollee's present
inpatient care needs, and the enrollee is receiving an appropriate level of care in the present setting. There are
no services available at the LTACH that the enrollee requires that are not available and covered in the
enrollee's current acute care setting. Continued care in the short-term acute care hospital is appropriate until the
enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a sub-acute
rehabilitation facility or a skilled nursing facility.
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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed (E0265).
You asked the Plan to pre-approve the total electric hospital bed. You say that you would like reconsideration
because you need an air pressure bed to prevent bed sores, a low height for transfers and a fully operational bed
where the head and feet of the bed go up and down. The Plan denied your request. The Plan says total electric
hospital beds are not covered and are denied as not medically reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital
bed (E0265).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve office visits to be provided by an out-of-network (OON)
provider for a second opinion.
You asked the Plan to pre-approve OON office visits. You say that the requested provider has a combination of
medical and religious experience. The Plan denied your request. The Plan says a second opinion is 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 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
office visits to be provided by an out-of-network (OON) provider for a second opinion.