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

We decided that the Plan has to pre-approve retainer crowns (D6750) for teeth # 22 and 27, and pontics (D6240) for teeth # 23, 24, 25 and 26.
You asked the Plan to pre-approve the dental services. You say that The Plan denied your request. The Plan says that retainer crowns are not listed as covered services. The Plan says pontics are not listed as covered services either.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that the services were denied based on the Office Reference Manual (ORM). We requested this document, but it was not received. The Plan has not substantiated their claim that the services are not covered. Without the ORM, we cannot determine if the requested services are not covered. Therefore, we decided that the Plan has to pre-approve retainer crowns (D6750) for teeth # 22 and 27, and pontics (D6240) for teeth # 23, 24, 25 and 26.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 19, 2020 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for lab tests. You say that you were not aware of the requirement of obtaining prior 
authorization. The Plan denied your request. The Plan says the denial of payment for this testing is correct, 
because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with 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 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 laboratory testing provided on November 19, 2020 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fluid Flow injections.
  
You asked the Plan to pre-approve the requested services. You say that you would like to try this to get some 
relief. The Plan denied your request. The Plan says the injections in the setting of thumb carpometacarpal 
degenerative joint disease has not been demonstrated in peer-review literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 requested services. Our physician 
reviewer found that you have bilateral thumb joint pain. The requested service is not FDA approved for 
injection in the carpometacarpal (CMC) joint.  Therefore, the request is not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Fluid Flow injections.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on May 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that you are a contracted provider, and the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
The record shows you are a non-contracted provider, and the laboratory work was referred by a non-contracted provider. Therefore, we decided that the Plan does not have to pay for laboratory work provided on May 17, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testosterone gel.
You asked the Plan to pre-approve Testosterone. The Plan denied your request. The Plan says Testosterone gel
to be administered at home is not covered under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Testosterone gel.
Benefits for Testosterone may be available under Medicare Part D. Contact the Plan that administers Part D
benefits for further information concerning any benefits and appeal rights
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for outpatient hospital services provided on June 4, 2021.
You asked the Plan to waive the copayment for outpatient hospital services. You say that you had an office visit across the street from the hospital. You say that you saw your urologist and paid the copayment for the office visit. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided records showing the services provided at the hospital. We are therefore unable to determine if the copayment applied is appropriate. Therefore, we decided that the Plan has to waive the copayment for outpatient hospital services provided on June 4, 2021.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory work provided on April 23, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory work. You say that the service is medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the laboratory work provided on April 23, 2021 by an out-of-network (OON) provider
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on July 1, 2021.
You asked the Plan to waive the copayment for a CT scan. You say that you feel that you should only owe one $250 copayment and not multiple copayments. 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 diagnostic radiology. You have been asked to pay a $250 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided on July 1, 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 you are appealing with supporting 
records. The Plan denied your request. The Plan says the denial of authorization for LTACH service is correct. 
 
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 receiving acute care services which have not been denied. The 
documentation does not support that the enrollee requires services at the LTACH that are not available at the 
acute care hospital where she is currently receiving 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve pain management services to be provided by an out-of-
network (OON) provider.  

You asked the Plan to pre-approve OON services. You say that this doctor has improved your quality of life. 
The Plan denied your request. The Plan says there are in-network providers 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve pain 
management services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computer-assisted surgery for muscle and bone procedure (20985) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve computer-assisted surgery for muscle and bone procedure. You say that this procedure is medically necessary. The Plan denied your request. The Plan says they have in-network providers available to provide this care.
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 computer-assisted surgery for muscle and bone procedure (20985) to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing provided on May 10, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 the drug testing provided on May 10, 2021 by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) visit you had on May 13, 2021.
You asked the Plan to waive the copayment for the ER visit. You say that this was a follow-up visit to take out stitches, so there should be no copayment. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this visit ($70.06) is less than your copayment obligation, you are responsible for the full allowed 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 room visits. You have been asked to pay a $90 copayment for the ER visit. This copayment applies regardless of the reason for the visit to the ER. 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 emergency room (ER) visit you had on May 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostate artery embolization (PAE) procedure. 
 
You asked the Plan to pre-approve PAE procedure. You say that this procedure only uses local anesthesia 
which is the best option for you. The Plan denied your request. The Plan says the denial of authorization for 
this service is correct, because PAE is experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 PAE procedure. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the American Urological Association states that PAE for the routine treatment of lower urinary 
tract symptoms or benign prostate hyperplasia is not supported by current data and benefit over risk remains 
unclear; therefore, PAE is not recommended outside the context of clinical trials. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PAE procedure have not been met. Therefore, we decided that the Plan does not 
have to pre-approve prostate artery embolization (PAE) procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for light therapy services provided from June 9, 2021, to June 23, 2021.
You asked the Plan to reduce the copayment for light therapy services. You say that you do not see the doctor at your visits. You say that the Plan should pay some more for your many treatments. The Plan denied your request. The Plan says you have been asked to pay 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 $40 copayment for therapy services provided at a specialist's office. You have been asked to pay the allowed amount of $20.84 for each visit, which is less than the $40 copayment for light therapy services at a specialist's office. Light therapy services fall within the Physician/Practitioner
Services, Including Doctor's Office Visits 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 reduce the copayment
for light therapy services provided from June 9, 2021, to June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Ustekinumab injection provided on September 22, 2020 by an out-of-network provider.
You asked the Plan to pay for Ustekinumab, for subcutaneous injection, 1 mg (J3357). You say that the enrollee gave the wrong insurance information. The Plan denied your request. The Plan says services were not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to pay for the item. Therefore, we decided that the Plan does not have to pay for Ustekinumab injection provided on September 22, 2020 by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission
and services.
You asked the Plan to pre-approve IRF care. You say that you would like the plan to reconsider their denial.
The Plan denied your request. The Plan says the requested admission 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 in the Medicare rules section.
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 you have a past medical history of stroke and is living at home with increasing
weakness and falling episodes. Your medical problems are stable. There are no complex nursing or
rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. Therefore, you care needs can be met 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the outpatient surgery services provided by an out-of-network hospital on August 29, 2018, and August 30, 2018.
You asked the Plan to waive the coinsurance for the outpatient surgery services. You say that this claim should have been paid as in-network. The Plan denied your request. The Plan says this coinsurance was charged correctly. The Plan says that this facility has been out-of-network since January 1, 2015, and remains out-of-network today.
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 40% coinsurance for surgery and other services at an out-of-network outpatient hospital facility.
The enrollee has been asked to pay 40% coinsurance for the outpatient surgery services. The Plan has confirmed that the facility where the services were received is out-of-network for the enrollee's plan. 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 coinsurance for the outpatient surgery services provided by an out-of-network hospital on August 29, 2018, and August 30, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for initial hospital care and subsequent hospital care provided on November 20, 2020, November 21, 2020, and November 22, 2020.
You asked the Plan to pay for initial hospital care (99223) subsequent hospital care (99232). You say that documents were submitted supporting services. The Plan denied your request. The Plan says there are no medical records supporting these procedures.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 99232 and 99223 are not supported in the medical record. Specifically, there are no records for the services on these dates of service. Based on this information, we decided that Medicare rules for coverage of initial hospital care (99223) subsequent hospital care (99232) have not been met. Therefore, we decided that the Plan does not have to pay for initial hospital care and subsequent hospital care provided on November 20, 2020, November 21, 2020, and November 22, 2020.