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

We decided that the Plan does not have to waive the copayments for the emergency room (ER) services you received on April 18, 2021 and the outpatient hospital observation services you received on April 19, 2021.
You asked the Plan to waive the copayments for the ER services and the hospital outpatient observation services. You say that you presented your Veterans' Affairs (VA) card to the hospital, so there should be no copayment. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that it is not aware if your claims have been sent to the VA, but you are welcome to submit the claims to the VA for consideration.
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 $75 copayment for emergency room visits and a $150 copayment for outpatient hospital observation services.
The records show that you went to the ER on April 18, 2021. You were evaluated but left against medical advice later that evening. On the following day, you returned to the hospital and were admitted for observation for trouble swallowing. You then had an upper gastrointestinal endoscopy and lab services prior to being discharged home. You have been asked to pay a $75 copayment for the ER services and a $150 copayment for the hospital outpatient observation 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 copayments for the emergency room (ER) services you received on April 18, 2021 and the outpatient hospital observation services you received on April 19, 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 LTACH services are medically necessary The Plan denied your request. The Plan says a transfer to an LTACH is not medically necessary. Once you complete your care in the current hospital, you may receive continued services in a lower level of care.
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 you appear to be receiving appropriate care currently but have a poor prognosis and should be appropriate for a lower level of care shortly. Until then, additional care may be safely provided at the current facility. You do not require services at the LTACH that are not already available to you and covered at the current facility. Therefore, this request for LTACH services is considered not medically necessary, as transfer would not provide a significant clinical advantage at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve molecular pathology.
You asked the Plan to pre-approve molecular pathology. You say that you would like the plan to reconsider
their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested
services.
The Plan must follow Medicare rules. Medicare rules say that molecular pathology procedures are only covered
for certain indications.
We looked at the file and Medicare rules. Review of the file does not support evidence that a specific genetic
test is needed to impact targeted immune system or drug therapy used to improve your prognosis and/ or
treatment plan. Based on this information, we decided that Medicare rules for coverage of molecular pathology
have not been met. Therefore, we decided that the Plan does not have to pre-approve molecular pathology.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a prosthetic leg replacement at the K3 level of ambulation.
You asked the Plan to pre-approve the lower limb prosthesis replacement. You say that the prosthetic leg replacement should be approved. The Plan denied your request. The Plan says the enrollee does not meet criteria for being a K3 ambulator.
The Plan follows Medicare rules. Medicare rules say that a lower limb prosthesis will reach or maintain a defined functional state within a reasonable period of time and is motivated to ambulate
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 lower limb prosthesis replacement. Our reviewer says that the service is not shown to be medically necessary. Our physician reviewer found the record indicates that the enrollee has a right below knee amputation. The records provided do not document objective evidence that the enrollee currently has the ability or potential for ambulation with variable cadence. The elements of the coverage criteria are not satisfied. The requested service is not recommended. 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 lower limb prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-approve a prosthetic leg replacement at the K3 level of ambulation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953).
You asked the Plan to pre-approve the guided tissue regeneration and bone replacement graft. You say that you currently have a sacral infection and would like these services to be reconsidered. The Plan denied your request. The Plan says these services are not covered under your dental 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 pre-approve a guided tissue regeneration (D4266) and bone replacement graft for ridge preservation (D7953).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services to be provided by a Licensed Professional Counselor.
You asked the Plan to pay for outpatient mental health services. You say that you have been seeing this provider for many years. The Plan denied your request. The Plan says this provider is not eligible for Medicare enrollment.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for outpatient mental health services to be provided by a Licensed Professional Counselor
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee appears to be functioning below her baseline. A period of skilled therapy for strength and endurance training is reasonable. Daily skilled services are required to establish a maintenance program and/or to prevent deterioration of the enrollee's 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
You asked the Plan to pre-approve the maxillary partial denture. You say that you need new dentures because your old ones do not fit correctly, and you are in a lot of pain. The Plan denied your request. The Plan says this service exceeds the benefit allowance.
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, dentures are limited to one set every 5 years. The record shows that you received a maxillary partial denture (D5213) on December 4, 2017 and your maxillary denture benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs. The enrollee does have documented skilled therapy needs. The enrollee is functioning below her baseline, but currently appears unable to participate in daily skilled therapy. The enrollee's care needs, as a practical matter, can be provided at a lower level of care. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve durable medical equipment to be provided by an out-ofnetwork
(OON) provider.
You asked the Plan to pre-approve durable medical equipment. You say that you would like approval for this
equipment. The Plan denied your request. The Plan says there are in-network physicians available to provide
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
durable medical equipment to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.

You asked the Plan to pre-approve the SNF admission. You say that you need to be able to gain strength in order to return home safely. The Plan denied your request. The Plan says you do not require daily skilled services on an inpatient basis at the SNF level of care.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 the SNF admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. Our reviewer found that you do not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. Our physician reviewer also found that you do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee and foot prosthesis at the K3 ambulation level.

You asked the Plan to pre-approve the knee and foot prosthesis. You say that the K3 knee and foot is medically
necessary. The Plan denied your request. The Plan says the enrollee is not a K3 ambulator.

The Plan follows Medicare rules. Medicare rules say that will reach or maintain a defined functional state
within a reasonable period of time and is motivated to ambulate.

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 knee and foot prosthesis. Our
reviewer says that the prostheses are not shown to be medically necessary. Our physician reviewer found the
record indicates that the enrollee has a below knee amputation. There are no records for the ordering physician
to support the request. The records provided do not document objective evidence that the enrollee currently has
the ability or potential for ambulation with variable cadence. The elements of the coverage criteria are not
satisfied. The requested service is not recommended.

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 knee and foot prosthesis have not been met. Therefore, we decided that the
Plan does not have to pre-approve a knee and foot prosthesis at the K3 ambulation level.
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 an LTACH is medically necessary for this enrollee and is essential for them to regain maximum function. The Plan denied your request. The Plan says the criteria for an LTACH are not met. The enrollee is receiving medically necessary acute and/or critical care in the current facility. An LTACH would not offer a clinical advantage.
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 record indicates that the enrollee is not clinically stable. The enrollee is receiving continued acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that they are not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied; the requested service cannot be recommended.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that you would be home the majority of the day
and wouldn't have the care and therapy needed. You say that you have not yet built the strength needed or
reached your baseline. The Plan denied your request. The Plan says the requirements for approval have not
been met. The Plan says that the records do not support the need for daily therapy on an inpatient basis.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section 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 the SNF services. Our reviewer says
that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have
documented skilled nursing needs. The enrollee does not have documented skilled therapy needs. Daily skilled
services are not required to establish a maintenance program or to prevent deterioration of the enrollee's
condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower level of
care.
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 SNF services have not been met. Therefore, we decided that the Plan does
not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for physical therapy.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your
request. The Plan says the service is available within 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
an out-of-network referral for physical therapy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eyeglasses to be provided by an OON provider.
You asked the Plan to pre-approve eyeglasses. You say that you tried to get your glasses at an in-network
location, but they were not made correctly, and they could not fix them. The Plan denied your request. The Plan
says you must use a Plan vendor to obtain eyewear benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan contract says you must use an eyewear vendor to obtain eyewear benefits.
We looked at the file and the Plan's rules. The provider in this case is not part of the Plan's vision network. The
Plan covers eyewear when they are received from a provider who participates in the Plan's specified vision
network. Please note, that the Plan has reinstated your benefits and you can obtain a new pair of frames and
lenses up to $300 of your maximum allowed amount, with one of the in-network providers. Based on this
information, we decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we
decided that the Plan does not have to pre-approve eyeglasses to be provided by an OON provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on May 23, 2021.
You asked the Plan to waive the copayment for emergency care. You say that you should not owe the
copayment because you were misdiagnosed. 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 $90
copayment for emergency care.
You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency
care 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 emergency care provided on
May 23, 2021.
We note your complaint that you were misdiagnosed. Your complaint is a grievance that must be answered by
the health plan. Medicare does not permit us to make a decision about these types of complaints.