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

We decided that the Plan does not have to waive the coinsurance for five (5) units of Hyalgan Supartz
injections (CPT code J7321) provided from October 13, 2020, through November 10, 2020.
You asked the Plan to waive the coinsurance for the injections. You say that you were not aware that you owe
anything since you had prior authorization on file. The Plan denied your request. The Plan says the claims were
processed accordingly with your 2020 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).
Review of the file show that you received Hyalgan Supartz injections (CPT code J7321) for five (5) dates of
service provided from October 13, 2020, through November 10, 2020. You have been asked to pay 20%
coinsurance of the allowed amount for the injection for each visit. The allowed amount is $79.81. The total you
owe for each visit is $15.96 ($79.81 x 20% = $15.96). Your total cost share responsibility is $79.80 ($15.96 x 5
dates of service = $79.80). Your 2020 EOC states that enrollees must pay 20% coinsurance for Medicarecovered
Part B Chemotherapy drugs and other Part B drugs. 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 five (5) units of Hyalgan Supartz injections (CPT code J7321) provided from October 13, 2020, through
November 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ultraviolet (UV) light therapy system.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that ultaviolet cabinets are covered for selected patients with generalized intractable psoriasis. We looked at the file and Medicare rules. The file shows that the UV light box therapy is being requested to treat atopic dermatitis. This is not a condition for which Medicare covers these services. Therefore, we decided that the Plan does not have to pre-approve an ultraviolet (UV) light therapy system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a ventilator (E0466).
You asked the Plan to pre-approve a ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met with BiPAP.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a ventilator. Our reviewer says that the requested ventilator is not medically necessary. Our physician reviewer found this patient has severe chronic obstructive pulmonary disease (COPD) with carbon dioxide retention and a recent exacerbation requiring hospitalization. The patient would likely benefit from BiPAP nightly at home, and some BiPAP devices can provide the mode of support that has been ordered. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a ventilator (E0466).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased on September 30, 2020.
You asked the Plan to pay for the hearing aids. You say that you are not satisfied with the hearing aids provided by the Plan's specified hearing vendor and feel that these are better quality and more effective. The Plan denied your request. The Plan says hearing aids purchased out-of-network are not covered.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are purchased from the Plan's specified in-network vendor. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the digital hearing aids (V5261) purchased on September 30, 2020.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergency ambulance transport services provided on
October 23, 2020.

You asked the Plan to pay for the non-emergency ambulance transport services. 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 member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare,
covers all hospice care from the effective date of election to the date of discharge or revocation.

During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to
the terminal illness until the first day of the month following the month in which hospice was revoked or
discharged.

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 non-emergency ambulance transport services provided on
October 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for agitation and confusion. Medical conditions are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the standard frames (V2020), progressive lens (V2781), vision item or service, miscellaneous (V2799) provided February 3, 2021.
You asked the Plan to pay for the frames, progressive lenses and miscellaneous vision item or service. You say that you were told you are eligible for eyewear every year and cannot afford the cost. The Plan denied your request. The Plan says standard frames and lenses are covered once every 2 years. Since eyewear was covered previously within this timeframe, the eyewear at issue is not eligible for coverage under your vision benefits
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine eyewear once every two years. We looked at the file and the Plan's rules. The Plan provided documentation that frames and lenses were previously covered on January 21, 2020. Based on this information, we decided that the Plan's rules for coverage of the frames, progressive lenses and miscellaneous vision item or service have not been met. Therefore, we decided that the Plan does not have to pay for the standard frames (V2020), progressive lens (V2781), vision item or service, miscellaneous (V2799) provided February 3, 2021.
Your complaint about potentially receiving confusing or inaccurate information about vision benefits not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the eyeglasses provided on
December 14, 2020.
You asked the Plan to pay an additional amount for the eyeglasses. You say that you were told by the provider that you were eligible for new eyeglasses and at no time were you told that you were not eligible. The Plan
denied your request. The Plan says your benefit only covers up to the maximum allowed amount of a $150 eyewear allowance. The $150 eyewear allowance was exhausted with this purchase.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum allowed amount of $150 toward the purchase of the eyeglasses. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on December 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) provided on November 7, 2020.

You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You
say that you believe these services should be covered. The Plan denied your request. The Plan says these
services exceed the frequency limitation in your benefit plan.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, comprehensive oral evaluation
(D0150) and complete series of intraoral x-rays (D0210) are each limited to one procedure every three plan
years. The record shows that you received a comprehensive oral evaluation (D0150) and complete series of
intraoral x-rays (D0210) on January 28, 2020 and your comprehensive oral evaluation (D0150) and complete
series of intraoral x-rays (D0210) benefits have been exhausted. Therefore, we decided that the Plan does not
have to pay for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210)
provided on November 7, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.

You asked the Plan to pre-approve these services. You say that you are paraplegic and need the bed to assist with mobility. The Plan denied your request. The Plan says the services are not covered.

The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. 

While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical nutrition therapy services provided on November
11, 2020.
You asked the Plan to pay for medical nutrition therapy services. The Plan denied your request. The Plan says
this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services
only for enrollees with renal disease or diabetes.
The records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the
Plan does not have to pay for the medical nutrition therapy services provided on November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy services provided from January 6, 2021, through January 27, 2021, by an in-network provider.
You asked the Plan to waive the copayment for the physical therapy services. You say that you believed you would not have a 'per visit' amount due. The Plan denied your request. The Plan says the claims were processed accordingly with your 2021 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). Review of the file show that you received physical therapy services from January 6, 2021, through January 27, 2021, by an in-network provider. You were asked to pay a $35 copayment per date of service for four (4) dates of service. Your 2021 EOC states that enrollees must pay a $35 copayment for in-network physical therapy
services. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the physical therapy services provided from January 6, 2021, through January 27, 2021, by an in-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 this is medically necessary. The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.
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 that while the patient does require physical and occupational therapy, there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a
different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse for the manual wheelchair (CPT code E2228) purchased on December 15, 2020, from a provider not Medicare certified.

You asked the Plan to reimburse for DME. You say that you can go out-of-network and you are looking for reimbursement. The Plan denied your request. The Plan says the provider is not a Medicare provider and is not enrolled in the Medicare program for DME.

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 reimburse for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider you purchased the DME from is not a Medicare provider and is not enrolled in the Medicare program for DME. We found no exception that would require the Plan to reimburse for these items/services. Therefore, we decided that the Plan does not have to reimburse for the manual wheelchair (CPT code E2228) purchased on December 15, 2020, from a provider not Medicare certified.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for arch support shoe insoles purchased on December 27, 2020.

You asked the Plan to pay for the insoles. You say that your doctor advised that these insoles would help with your foot issues and alleviate pain while walking and performing daily routines. The Plan denied your request. The Plan says this item is not covered by Medicare, nor is it covered by the Plan's supplemental wellness benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The rules also say that Medicare does not cover health and wellness benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to $300 annually for health and wellness benefits including membership in a health club or fitness facility, acupuncture, nutrition counseling, and participation in instructional fitness classes. The Plan also states that this allowance may be used for additional items from October 1, 2020, to December 31, 2020, due to the current pandemic. The Plan says that during this period, the benefit may also cover exercise equipment used at home, such as: treadmills, exercise bikes, ellipticals, free weights, resistance bands, weight stations, jump ropes, yoga mats, and subscription services to online classes.

The Plan's rules for coverage of health and wellness benefits have not been met because the requested shoe insole is not listed as an item that may be covered under this benefit. The rules for Medicare coverage are also not met, as the insole is not an integral part of a leg brace and there is no evidence that they are being used for a diabetic foot disease. Therefore, we decided that the Plan does not have to pay for arch support shoe insoles purchased on December 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay fora Garmin watch purchased on November 25, 2020.

You asked the Plan to pay fora Garmin watch. You say that you want the Plan to pay for the item.The Plan denied your request. The Plan says the item at issue is not covered.

The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

The Plan's rules for coverage of gym benefits have not been met because the item at issue is not covered by the Plan.Therefore, we decided that the Plan does not have to pay for a Garmin watch purchased on November 25, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Udenyca for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical rationale as to why the preferred alternatives cannot be used.
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 the drug. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found the plan requires a trial of Zarxio and Ziextenzo before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indication that the required drugs would likely be less effective and/or likely 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 the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Udenyca for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an implant removal (D6100) provided on November 14, 2018.

You asked the Plan to pay for an implant removal. You say that the service should be covered. The Plan denied your request. The Plan says the service at issue is not a covered benefit.

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 an implant removal (D6100) provided on November 14, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99204) rendered by the out of network (OON) provider on December 3, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the office visit (99204) rendered by the out of network (OON) provider on
December 3, 2020.