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

We decided that the Plan does not have to pre-approve Tecentriq (J9022).
You asked the Plan to pre-approve Tecentriq. You say that the requested medication is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Tecentriq. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Tecentriq is FDA approved for the treatment of unresectable or metastatic hepatocellular carcinoma (in combination with bevacizumab) in enrollees who have not received prior systemic therapy. This enrollee has already received treatment with lenvatinib. There are no off-label indications. The service is not reasonable or medically 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 Tecentriq have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq (J9022).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the filling (D2391) and root canal (D3330) provided February 8, 2020.You asked the Plan to pay for the dental services. You say that you went for an emergency dental procedure and was surprised when you came out of the procedure and was told the plan will not cover the services.The Plan denied your request. The Plan says these services are not covered under the plan 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 pay for the filling (D2391) and root canal (D3330) provided February 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a hymovisinjection provided by a participating provider on December 20, 2019 and January 3, 2020.You asked the Plan to waive the coinsurance for an injection. You say that if you would have known that these injections were going to be this expensive you would have gone with the cheaper injections. The Plan denied your request. The Plan says the correct coinsurance has 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 20% coinsurance for Medicare Part B prescription drugs/in-network. You have been asked to pay a 20% coinsurance of the allowed amount for an injection. The total allowed amount is $2,370.72. The total amount you are being asked to pay is $474.14 ($2,370.72 x 20% = $474.14). The total an injection falls within the Medicare Part B prescription drugs/in-network 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 coinsurance for a hymovis injection provided by a participating provider on December 20, 2019 and January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an urgent care visit (S9083) provided on September 30, 2018 and an office visit (99213) and an injection (J0702) provided on October 23, 2019. You asked the Plan to waive the cost-sharing for an urgent care visit, an office visit, and an injection. You say that these services should be fully covered. The Plan denied your request. The Plan says these services processed correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each specialist office visit and a 20% coinsurance for Part B drugs. You have been asked to pay $40 for an urgent care visit, $40 for an office visit, and $2.78 (20% of the total allowable amount) for an injection. 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 cost-sharing for an urgent care visit (S9083) provided on September 30, 2018 and an office visit (99213) and an injection (J0702) provided on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99205) provided on July 29, 2019 by an out of network (OON) provider.You asked the Plan to pay for an OON office visit. You say that the enrollee was referred for this service following an emergency room visit.The Plan denied your request. The Plan says this service was 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 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 office visit (99205) provided on July 29, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on January 2, 2020 to February 20, 2020 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that it is more convenient for you to have these services at your assisted living facility. You say that you have transportation issues getting to your PCP. 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 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 physician services provided on January 2, 2020 to February 20, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 27, 2020 by an out of network (OON) provider. You asked the Plan to pay for the outpatient visit (99214). You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits. 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 medical services provided on January 27, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for eyeglass frames, lenses and contact lenses purchased on January 9, 2019.
You asked the Plan to pay for the eyeglass frames, lenses and contact lenses. You say that the claim was timely within 15 months. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the eyeglass frames, lenses and contact lenses was not filed until March 11, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for eyeglass frames, lenses and contact lenses purchased on January 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation (64625).
You asked the Plan to pre-approve radiofrequency ablation. You say that previous radiofrequency ablation has
been successful. The Plan denied your request. The Plan says this is experimental.
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 radiofrequency ablation. Our reviewer
says that the requested services are not considered medically reasonable and necessary in this case. Our
physician reviewer found this is considered an experimental/ investigational procedure because of the wide
range of efficacy in the peer-reviewed literature.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of radiofrequency ablation have not been met. Therefore, we decided that the Plan
does not have to pre-approve radiofrequency ablation (64625).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 22, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 physician's services provided on January 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on December 17, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you don't why you are expected to pay this much for an emergency transport. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $265 copayment per date of service regardless of the number of ground ambulance trips. You have been asked to pay a $265 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 ambulance transport provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit with an out-of-network tertiary level of
care provider.
You asked the Plan to pre-approve tertiary level office visit. You say that you have seen this provider in the
past and want to receive care from them again. The Plan denied your request. The Plan says the denial of
authorization for this service is correct, because this provider is out-of-network with the Plan and you can be
treated by an in-network non-tertiary urologist.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan
providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you
must use contract providers for care.
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 tertiary level office visit. Our reviewer
says that you do not meet the Medicare criteria for the requested tertiary level of care visit. Our physician
reviewer found the Plan is offering adequate care to meet your medical needs through its referral to an in-network
community level urologist. There is nothing unique about your condition that would make it medically
necessary for you to see the requested out-of-network tertiary level of care provider. The Plan has shown that
they have community-level providers who meet the standards of care required for treatment of your 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 tertiary level office visit have not been met. Therefore, we decided that the Plan
does not have to pre-approve an office visit with an out-of-network tertiary level of care provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the wheelchair provided on March 12, 2020.You asked the Plan to waive the coinsurance for the wheelchair. You say that you haven't received anything from this company.The Plan denied your request. The Plan says the coinsurance applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies.You have been asked to pay $8.80, which is 20% of the allowed amount for the wheelchair. The allowed amount is $44.04 (20% x $44.04 = $8.80). The wheelchair falls within the "Durable medical equipment (DME) and related supplies" benefit category. The records show that you received the wheelchair. 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 coinsurance for the wheelchair provided on March 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray provided on February 24, 2020.You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 theservice 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 anx-ray provided on February 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on January 9, 2020 by an
out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that it is the facility's responsibility to obtain
prior authorization. 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 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 skilled nursing services provided on January 9,
2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and laboratory test provided on January 17, 2019.
You asked the Plan to pay for office visit and lab test. You say that you submitted the claim to Original Medicare in a timely manner. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this claim was not submitted within the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for office visit and lab test was not filed until January 21, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an office visit and laboratory test provided on January 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on December 9, 2019.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says an appropriate modifier has not been billed on the claim.
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 code 99291 is not supported in the record. Specifically, the record indicates the CPT code 36556 has been approved and paid for this date of service. CPT code 99291 has not been submitted with an appropriate modifier to indicate that the critical care was a significant, separately identifiable evaluation and management service that was above and beyond the usual pre and pose-operative care associated with the procedure that was performed. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forintraoral-periapical-first x-ray (D0220), Bitewings -two x-rays  (D0272) and palliative (emergency)care (D9110) provided March 2, 2020.You asked the Plan to pay forthe dental services. You say that you are being billed for an emergency treatment and you disagree with that this was an emergency . The provider did the evaluation and determined there was another issue.The Plan denied your request. The Plan says this claim was processed correctly and the plan paid the maximum allowable.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 are covered up to $300 for covered dental services. You pay 100% for all other services. If you choose to go to a dentist out of the network, you may pay more. The dentist can bill for additional costs if what they charge is more than the maximum benefit amount for covered services. for Dental services. You have been asked to pay $138 for the dental services. The services fall within the Dental 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 pay forintraoral-periapical-first x-ray (D0220), Bitewings -two x-rays (D0272) and palliative (emergency) care (D9110) provided March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary, rest home visit provided on February 3, 2020.You asked the Plan to pay for the domiciliary, rest home visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 a domiciliary, rest home visit provided on February 3, 2020.