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

We decided that the Plan does not have to waive the copayment for a specialist office visit, an x-ray and an MRI and coinsurance for an injection provided by participating providers on November 27, 2019 to February 10, 2020.
You asked the Plan to waive the copayment for a specialist office visit, an x-ray and an MRI and coinsurance for an injection. You say that all these visits were unnecessary because the doctor said you didn't need an MRI. You say that the Plan made you go back and get the MRI. The Plan denied your request. The Plan says the correct copayments and coinsurance have been applied.
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 $30 copayment for practitioner/physician services/specialist office visit, a $30 copayment for outpatient diagnostic tests/x-ray, a 20% coinsurance for Medicare Part B drugs and a $250 copayment for outpatient diagnostic tests/advanced imaging services. You have been asked to pay a $30 copayment for a specialist office visit, a $30 copayment for an x-ray, a 20% coinsurance of the allowed amount for an injection and $206.49 for an MRI, which is less than your copayment amount of $250. The amount that you are being asked to pay for the injection is $2.50 ($12.50 x 20% = $2.50). The total amount you are being asked to pay is $328.99 ($30 + $30 + $2.50 + $30 + $206.49 + $30 = $328.99). a specialist office visit falls within the practitioner/physician services/specialist office visit benefit category. An x-ray falls within the outpatient diagnostic tests/x-ray benefit category. An injection falls within the Medicare Part B drugs benefit category. An MRI falls within the outpatient diagnostic tests/advanced imaging 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 a specialist office visit, an x-ray, and an MRI and coinsurance for an injection provided by participating providers on November 27, 2019 to February 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim was not billed correctly.
The Plan must follow Medicare rules. The rules say that inpatient services should be billed on an 11x type of bill. We looked at the file and Medicare rules. The claim for inpatient hospital services was not billed with the correct type of bill. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe endodontic therapy provided on December 10, 2019.You asked the Plan to pay forthe endodontic therapy. You say that you were not able to find an in-network provider for the treatments you needed. You also say that your symptoms worsened and became an emergency due to the delay.The Plan denied your request. The Plan says this service is 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, the requested items or services are not among those coveredunder this benefit.Therefore, we decided that the Plan does not have to pay forthe endodontic therapy provided on December 10, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient surgery services provided on January 3, 2020.You asked the Plan to pay for the outpatient surgery. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient surgery services provided on January 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durvalumab.
You asked the Plan to pre-approve Imfinzi. The Plan denied your request. The Plan says the use of the drug requires that the enrollee has stage III disease and have not progressed on prior PD1/PD-L1 therapy.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Imfinzi. Our physician reviewer found that the requested use of Imfinzi is not FDA-approved for the enrollee's diagnosis. Treatment is for unresectable stage III non-small cell lung cancer in adults whose disease has not progressed following concurrent platinum-based chemotherapy and radiation therapy. This enrollee is stage IV given multiple recurrences. The requested use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. Therefore, the requested drug is not considered medically reasonable and 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 Imfinzi have not been met. Therefore, we decided that the Plan does not have to pre-approve Durvalumab.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, prophylaxis, and complete series of intraoral x-rays provided by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, prophylaxis, and complete series of intraoral x-rays. You say that this provider is listed in the Plan's book of provider's, but the office you saw him at is newer and not listed in the provider books. The Plan denied your request. The Plan says these services were rendered by a non-contracted provider. The Plan also says that there are in-network providers within the time and distance standards set forth by Medicare.
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 covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, prophylaxis, and complete series of intraoral x-rays provided by an OON provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on November 22, 2019.
You asked the Plan to pay for the nursing facility care. You say that the service was medically necessary. The Plan denied your request. The Plan says the services were not emergent. There were 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the nursing facility care (99308) provided on November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the commode chair purchased on January 2, 2020.You asked the Plan to reimburse you for the commode chair. You say that this provider is the only one in your area within 75 miles.The Plan denied your request. The Plan says this provider is not a Medicare provider and does not participate in Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. Payment cannot be made for items purchased from this provider because this provider is not a medical provider and is not enrolled in Medicare.Therefore, we decided that the Plan does not have to reimburse you for the commode chair purchased on January 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided on November 27, 2019.
You asked the Plan to pay for the perfusionist services (99190). You say that that this equipment was provided to the enrollee during an inpatient stay and should be covered. The Plan denied your request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services. The Plan says that this claim should be submitted to the facility.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. This equipment was used during and after a surgical procedure by the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility or hospital. --Therefore, we decided that the Plan does not have to pay for assembly and operation of pump with oxygenator or heat exchanger provided on November 27, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on November 13, 2019.You asked the Plan to pay for the domiciliary or rest home visit. You say that you do not agree with the determination that was made on this claim.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 enrollee'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 domiciliary or rest home visit provided on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam.
You asked the Plan to waive the copayment for the medical eye exam. The Plan denied your request. The Plan says that you are contractually obligated to pay appropriate copay for each Medicare approved visit.
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 $35 copayment for each visit to a specialist, such as an ophthalmologist or optometrist, for Medicare-covered benefits. You have been asked to pay a $35 copayment for the medical eye exam. The medical eye exam falls within the visit to a specialist for Medicare-covered benefits 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 medical eye exam.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of pacing electrode for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee did not have an ejection fraction of less than 50%.
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 procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records, the enrollee has persistent symptomatic atrial fibrillation, and an ejection fraction over 50%. In this circumstance, bi-ventricular pacing followed by AV Nodal ablation has been shown to be helpful only in patients with a baseline ejection fraction of less than 50%. Coverage criteria are not met since the procedure in appeal has not been shown to be beneficial in the subset of patients with normal ejection fraction and should be considered investigational in this setting. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of pacing electrode for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claims were processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Page 72 of your 2019 EOC says that the member must pay $195 co-pay each day for days 1-7 for inpatient
hospital care, per admission. The Plan received a claim from the provider for a 5-day inpatient hospital admission. The claim was paid by the Plan on December 3, 2019 with $975 co-pay ($195/day x 5 days = $975) as stipulated by your contract. The Plan received a claim from the provider for a 5-day inpatient hospital admission and was paid by the Plan on December 3, 2019 with $975.00 co-pay ($195/day x 5days = $975). The Plan received a claim from the provider for a 6-day inpatient hospital admission and was paid by the Plan on December 24, 2019 with $720.00 co-pay. The cost share was lowered as you met your maximum out-of-pocket. 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 inpatient hospital care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX for the enrollee.You asked the Plan to pre-approve Supartz FX. You say that the enrollee has bilateral osteoarthritis.The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.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 Supartz FX. Our reviewer says that Supartz FX is not medically reasonable and necessary for the enrollee in this case. The provided medical records do not indicate that the enrollee has tried and failed Monovisc or that it would likely be less effective and/or likely have adverse effects for the enrollee. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Supartz FX. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met.Therefore, we decided that the Plan does not have to pre-approve Supartz FX for the enrollee.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost forthe interrogation deviceevaluation. We decided that the Plan does not have to waive the cost forthe interrogation device evaluation. You asked the Plan to waive the cost forthe interrogation device evaluation. You say that you shouldn't be charged an office visit for a radiologist to read your test results. The Plan says that the copayment applied correctly.We decided that the Planhas to reduce the cost forthe interrogationdeviceevaluation. The pacemaker evaluation is considered a diagnostic test. This means that you are only responsible for 20% of the allowed amountforthe interrogation device evaluation. The allowed amount is $30.06 (20% x $30.06 = $6.01). Therefore, we decided that the Plan has to reduce the cost forthe interrogation device evaluationfrom $30.06 to $6.01. We also decided that the Plandoes not have to waive the cost forthe interrogationdevice evaluation.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 20% coinsurance for other outpatient diagnostic tests.Therefore, we decided that the Plan does not have to waive the cost forthe interrogation device evaluation. We also decided that the Plandoes not have to waive the cost forthe interrogationdevice evaluation.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 20% coinsurance for other outpatient diagnostic tests.Therefore, we decided that the Plan does not have to waive the cost forthe interrogation device evaluation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drugs or medicaments dispensed in the office for home use provided on January 9, 2020.You asked the Plan to pay forthe drugs or medicaments dispensed in the office for home use. You say that you asked to be signed up for the additional dental policy, and were told that you would be covered for the service.The Plan denied your request. The Plan says this service is not covered.Medicare generally does not cover dental services. However, the Plan offers adental 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 pay forthe drugs or medicaments dispensed in the office for home use provided on January 9, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried zoledronic acid as required by step therapy rules.
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 Prolia. Our reviewer says that The criteria for coverage of Prolia have not been met. Our physician reviewer found the Plan requires either a trial of drug zoledronic acid or a history of osteoporosis-related fracture before they will approve the requested drug. There is no reported history of osteoporosis-related fracture for the enrollee. The provided medical records do not indicate that the enrollee has tried and failed required zoledronic acid or that this drug would likely be less effective or have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says therapy needs can be met in an alternate 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 above 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee