Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pre-approve additional routine transportation trips (A0120).  You asked the Plan to pre-approve additional routine transportation trips. You say that you need to get to medical appointments. The Plan denied your request. The Plan says that you have utilized the maximum number of transportation trips allowed per year.  Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers additional routine transportation trips up to 52 one-way trips per calendar year.   We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Plan's rules for coverage of additional routine transportation trips have been met. Specifically, documentation does not show that you have exceeded the frequency limit for routine transportation. Therefore, we decided that the Plan has to pre-approve additional routine transportation trips (A0120).   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 pay more for the fixed bridge provided on June 30, 2021.  You asked the Plan to pay more for the fixed bridge. You say that authorization was established and confirmed by the office. You say that you would not have had the work done if they had told you what you would owe sooner. The Plan denied your request. The Plan says your benefit maximum for this time period has been reached.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of $5,000 for covered dental services every year. The Plan paid $5,000 toward the dental services received on June 17, 2021 and June 30, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the fixed bridge provided on June 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 4, 2021, through June 5, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that an inpatient admission was medically necessary. The Plan denied your request. The Plan says an inpatient admission was not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found that the enrollee is a 64-year-old female with Parkinson's disease who presented to the hospital for deep brain stimulation therapy and monitored while managed with morphine for her headache, then was discharged soon afterward. She was stable throughout. The enrollee's low risk, low complexity clinical presentation, risk factors, and procedure did not demand a need for hospital services that would likely cross 2 midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 4, 2021, through  June 5, 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 the enrollee's current facility is near bed capacity, and it is necessary for the enrollee to continue care at the LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is not safe to leave the current facility at this time as they have not completed the full course of care. The enrollee is receiving the appropriate care in the current acute care hospital and there is no advantage in transferring to an LTACH at this time.  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 requested information from the enrollee's current facility to verify if the facility is currently overburdened due to the current public health emergency. The facility confirmed that at this time they are not overburdened. 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 provided records show that the enrollee had been gradually improving but is experiencing worsening with diarrhea which needs to be treated and should only require short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Therefore, LTACH services will be considered not medically necessary at this time as transfer would not be clinically advantageous. Transfer to a lower level of care may be considered when treatment has completed and the enrollee is more stable.   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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the physical therapy provided from April 1, 2021, through May 21, 2021.  You asked the Plan to waive the copayment for the physical therapy. You say that you did pay the copayment every visit. 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 $40 copayment for each physical, occupational, and speech therapy visit.   You have been asked to pay a $40 copayment for each physical therapy visit. The physical therapy falls within the Outpatient Rehabilitation 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 physical therapy provided from April 1, 2021, through May 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the consultation to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve the out-of-network consultation. You say that you would like reconsideration because you would like this provider to review your scans while you wait to be directed in-network. The Plan denied your request. The Plan says there are in-network providers available to render your necessary 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 the consultation 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 pre-approve the crown (D2740) and core buildup (D2950).  You asked the Plan to pre-approve the crown (D2740) and core buildup (D2950). You say that the services are medically necessary to improve your health and you don't have the income to pay for the dental services. The Plan denied your request. The Plan says the services are not covered benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the crown (D2740) and core buildup (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635, 64636).  You asked the Plan to pre-approve the radiofrequency ablation procedure. You say that the ablation procedure is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.  The Plan must follow Medicare rules. Medicare rules say that for each covered spinal region no more than two (2) radiofrequency sessions will be reimbursed per rolling 12 months.  We looked at the file and Medicare rules. The record shows 2 ablation procedures have already been provided in the last 12 months. Based on this information, we decided that Medicare rules for coverage of the radiofrequency ablation procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a radiofrequency ablation procedure (64635, 64636).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve incontinence supplies.  You asked the Plan to pre-approve incontinence supplies. You say that incontinence supplies are medically necessary. The Plan denied your request. The Plan says incontinence supplies are not covered by Medicare.  The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable.   While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a vacuum erection device (L7900).  You asked the Plan to pre-approve a vacuum erection device. You say that a vacuum erection device is medically necessary. The Plan denied your request. The Plan says a vacuum erection device is not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules specifically state the requested device is not covered.  While this device may be beneficial for your use, it is not covered by the Plan or Medicare. Therefore, we decided that the Plan does not have to pre-approve a vacuum erection device (L7900).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis 5mg tablets.  You asked the Plan to pre-approve Eliquis. You say that Eliquis is medically necessary. The Plan denied your request. The Plan says this drug is not eligible for coverage under the Part B medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis 5mg tablets.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay more for the crown provided on July 26, 2021.  You asked the Plan to pay more for the crown. You say that you have not been to the dentist since early 2020 and do not understand why your calendar year maximum has been met. The Plan denied your request. The Plan says the claim reprocessed to pay an additional $50 leaving a member responsibility of $630.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.     Though the Plan offers a dental benefit in excess of Medicare coverage, you also have a maximum benefit of $500 every year for supplemental preventive and comprehensive dental services. The Plan paid $550 for the crown provided on July 26, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay more for the crown provided on July 26, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Neulasta.  You asked the Plan to pre-approve Neulasta. The Plan denied your request. The Plan says the enrollee has not tried and failed Zarxio, Ziextenzo, or another biosimilar pegfilgrastim product such as Fulphila, Nyvepria, or Udenyca.  Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Neulasta. Our physician reviewer found that in this case, the record indicates the enrollee has metastatic colon cancer. The requested medication is a new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve hereditary cancer panel testing.  You asked the Plan to pre-approve genetic testing. You say that this testing is medically necessary and will have a direct impact on medical management. The Plan denied your request. The Plan says the denial of authorization for this testing is correct, because the enrollee does not have a cancer that would support germline testing and this is not a Medicare-covered screening service.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The record shows that the enrollee's treating physician recommended this testing to determine if the enrollee may have a genetic variant that may increase risk of cancer, with the results requested to determine additional screening recommendation and preventive therapies/procedures. The record does not show that the results are being requested for the diagnosis or treatment of a specific medical condition. This is considered to be screening testing, which is not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve hereditary cancer panel testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the guided tissue regeneration (D4266 x 2), radiographic/surgical implant index (D6190), extraction (D7210), removal of residual tooth roots (D7250), and bone replacement graft for ridge preservation (D7953) provided on July 4, 2021.  You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says the guided tissue regeneration, radiographic/surgical implant index, extraction, removal of residual tooth roots, and bone replacement graft for ridge preservation are not listed as covered services.  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 guided tissue regeneration, radiographic/surgical implant index, extraction, removal of residual tooth roots, and bone replacement graft for ridge preservation are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration (D4266 x 2), radiographic/surgical implant index (D6190), extraction (D7210), removal of residual tooth roots (D7250), and bone replacement graft for ridge preservation (D7953) provided on July 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the echocardiogram provided on October 16, 2020.  You asked the Plan to waive the copayment for the echocardiogram. You say that your technician was overworked and incompetent. You say that since you had to visit another cardiologist, you do not think you should pay any copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount. The Plan denied your request.  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 $125 copayment for radiological diagnostic services, not including x-rays.   You have been asked to pay a $125 copayment for the echocardiogram. The echocardiogram 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 the echocardiogram provided on October 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for a specialist visit provided on June 11, 2021.  You asked the Plan to waive the deductible for a specialist visit. You say that you disagree with the charges because you met your deductible. 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. Your contract with the Plan says that there is a $500 deductible which applies to physician/practitioner services, including doctor's office visits. Your contract with the Plan also clearly says that after the $500 deductible has been met, enrollee's must pay a $10 copayment for specialist visits.   You had a specialist visit on June 11, 2021. The record shows that you had only paid $425.73 toward the $500 deductible prior to receiving the services due to the reprocessing of claims. Therefore, you are responsible to pay the remaining deductible balance of $74.27. Now that the $500 deductible has been met, you are also responsible to pay the $10 copayment. The total amount you owe is: $84.27.   The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to physician/practitioner services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time a specialist visit was received on June 11, 2021. Therefore, we decided that the Plan does not have to waive the deductible for a specialist visit provided on June 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for the office visit provided on March 15, 2021.  You asked the Plan to waive the deductible for the office visit. You say that this is a preventative service, and the deductible does not apply. The Plan denied your request. The Plan says the correct amount was applied to your deductible.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $290 deductible which applies to covered services.  The item or service in which you asked the Plan to waive the deductible falls within the Physician/Practitioner Services, Including Doctor's Visits benefit category. The record shows you were not charged for the annual wellness services you received. However, the record also shows you received additional services that went beyond the scope of an annual wellness visit. The additional services are subject to the deductible. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $290 deductible which applies to covered services. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on March 15, 2021. Therefore, we decided that the Plan does not have to waive the deductible for the office visit provided on March 15, 2021.