Persius/hicric huggingface dataset:
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 the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 services are not medically necessary. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. In this case, the member is mostly MODERATE to MAX assist for functional transfers and activities of daily living (ADL's) and a less intensive, longer duration of therapy may be more appropriate. It is not clear the enrollee would be able to fully benefit and/or participate in an IRF level of care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Gel-one injection (J7326).
You asked the Plan to waive the coinsurance for a Gel-one injection. You say that you believe this service was billed incorrectly. The Plan denied your request. The Plan says this service 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). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for each Medicare-covered Part B drug. The enrollee has been asked to pay $214.94 ($1,074.72 allowed amount x 20% coinsurance = $214.94) for a Gel-one injection. The record shows that the enrollee received Gel-one on the date of service in question. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a Gel-one injection (J7326).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea retainer crown (D6752) for teeth # 20 and 22, and a pontic (D6211) for tooth # 21.You asked the Plan to pre-approvethe dental services. You say that you need the dental bridge to cover the  missing tooth. You also say that you need to a bridge between the good teeth of this gap.The Plan denied your request. The Plan says porcelain crowns are covered for teeth # 5 to 12 and teeth # 22 to 27, and pontic crowns are covered for teeth # 6 to 11 and teeth # 22 to 27. The Plan also says that bridges are covered to replace only 1 upper front tooth or only 2 adjacent lower front teeth.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 dental services are not among those covered under this benefit. The dental services are not covered for the teeth that are being requested.Therefore, we decided that the Plan does not have to pre-approvea retainer crown (D6752) forteeth # 20 and 22, and a pontic (D6211) for tooth # 21.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDurolane (J7318).You asked the Plan to pre-approveDurolane. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried and failed Monovisc and Orthovisc 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 indicatesthat 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 Durolane. Our reviewer says that the criteria for coverage of Durolane have not been met. Our physician reviewer found the Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. The documentation does not support that the enrollee has tried and failed the required drugs or that Monovisc and Orthovisc would likely be less effective or have adverse effects for the enrollee in this case.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met.Therefore, we decided that the Plan does not have to pre-approveDurolane (J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Mohs surgery and repair services provided on August 19,
2019 by the out of network provider.
You asked the Plan to pay for the Mohs surgery and repair services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered
benefit.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 Mohs surgery and repair services provided on
August 19, 2019 by the out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from October 10,
2019 to October 13, 2019.
You asked the Plan to pay for the inpatient hospital services. You say that the treating physician exercised their
expert opinion in electing to admit this enrollee out of concern that the enrollee's symptoms were attributed to
an escalating clinical condition. 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. Original Medicare is responsible for payment for services until the first day of the month after the
hospice election has been revoked or terminated.
The enrollee ended Medicare Hospice benefits on October 10, 2019. The services in question were provided
before the end of that month. Therefore, we decided that the Plan does not have to pay for the inpatient hospital
services provided from October 10, 2019 to October 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam radiation therapy.
You asked the Plan to pre-approve proton beam radiation therapy. You say that the requested proton beam radiation therapy is medically necessary. The Plan denied your request. The Plan says the requested proton beam radiation therapy is not medically necessary.
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 proton beam radiation therapy. Our reviewer says that the requested proton beam radiation therapy is not medically necessary. Our physician reviewer found the enrollee is with a diagnosis of malignant neoplasm of prostate, T1c, Gleason 7(4+3). NCCN Guidelines Version 4.2019 - August 19, 2019 for Prostate Cancer states that the NCCN Panel believes no clear evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. "Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry." The documentation in the case file does not support that dose constraints to normal tissues limit the total dose of radiation safely deliverable to the tumor with other indicated methods. The documentation does not support that there is a reason to believe that doses generally thought to be above the level otherwise attainable with other methods might improve control rates. The documentation does not support that higher levels of precision associated with proton beam therapy as compared to other radiation methods are necessary. The documentation does not adequately demonstrate that Proton beam radiotherapy is considered the treatment of choice for this enrollee, and does not address the risk to normal tissue, the risk of disease recurrence, and the advantages of the treatment over IMRT or 3-dimensional conformal Dosimetric, evidence of reduced normal tissue toxicity, and/or improved tumor control. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve proton beam radiation therapy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe diagnostic mammogram on October 16, 2019.You asked the Plan to waive the copayment forthe diagnostic mammogram. You say that you are appealing this because you had breast cancer and you need to have the mammogram to make sureit does not come back. You say you have never been charged before for a mammogram. 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, accurateterms 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 basic imaging service (e.g., general x-rays or ultrasounds). You have been asked topay a $40 copayment for the diagnostic mammogram. The diagnostic mammogram falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows a history of breast cancer which makes the mammogramdiagnostic in nature. 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 Plandoes not have to waive the copayment forthe diagnostic mammogram on October 16, 2019.
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 you need the supplies and the Plan should cover them. The Plan denied your request. The Plan says this item is not a covered benefit.
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 pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 28, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on June 28, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approve echocardiography (93307).
You asked the Plan to pre-approve echocardiography. You say that the echocardiography is medically
necessary. The Plan denied your request. The Plan says that the echocardiography is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is medically 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 echocardiography. Our reviewer says
that the requested items/services are considered medically reasonable and necessary in this case. Our physician
reviewer found based on the records provided you have a documented new cardiac murmur. Current guidelines
consider echocardiography appropriate for evaluation of a new murmur in patients for whom there is
reasonable suspicion of valvular or structural heart disease.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of echocardiography have been met. Therefore, we decided that the Plan has to
pre-approve echocardiography (93307).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 3, 2019 by an out-ofnetwork
provider.
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 services were rendered by an out-of-network provider without 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 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 July 3, 2019 by
an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on September 27, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that this visit was a follow-up appointment from a procedure administered a few days prior. You say the copayment should be included in the original procedure's copayment. 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 $35 copayment per specialist visit. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a procedure.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 forthe specialist office visit provided on September 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the sleep studies provided on April 27, 2019 and May 28, 2019.
You asked the Plan to waive the copayment for the sleep studies. You say that you should not be responsible for both copayments because you were sent home from the first sleep study. 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 $150 copayment for all other in-network diagnostic procedures and tests. You have been asked to pay a $150 copayment for each of the sleep studies. The sleep studies fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows that services were provided on both dates of service.
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 sleep studies provided on April 27, 2019 and May 28, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were having difficulty breathing and
your daughter called for emergency services. When the ambulance arrived, the responders checked you and
gave you breathing treatment. You say that the responders made sure you were okay, but due to the distance of
the nearest hospital you were not transported. You believe the Plan should cover the claim because it was an
emergency. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on August 29, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ECG provided on July 23, 2019.You asked the Plan to waive the copayment foran ECG. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for outpatient diagnostic tests. You have been asked to pay a $20 copayment for an ECG. An ECG 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 foran ECG provided on July 23, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe vision services, frames and lenses purchasedon September 26, 2019.You asked the Plan to pay forthe vision services. You say that you had an eye exam and glasses the plan did not pay the correct amount and you are requesting review.The Plan denied your request. The Plan says the claim processed according to the plan benefit with the non-participating provider.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 any amount over the $100 for Vision care.You have been asked to pay $243.88. You pay any amount over the $100 allowed benefit. The provider charged $404.85 minus $100 benefit allowance ($304.85) and plan payment of $60.97 = $243.88 for the vision services. The vision services fall within the Vision care 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 forthe vision services, frames and lenses purchasedon September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on January 29, 2019.You asked the Plan to pay for the orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on January 29, 2019.