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

We decided that the Plan does not have to waive the copayment for a SNF stay provided from August 26, 2020, to October 1, 2020.
You asked the Plan to waive the copayment for a SNF stay. You say that you disagree with the charges because you fell and hit your head which required an additional 20 day stay. 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 $0 copayment for days 1-20, and a $178 copayment for days 21-100 for SNF care. You had a SNF stay from August 26, 2020, to October 1, 2020. You are not being charged a copayment for days 1-20 (August 26, 2020, to September 14, 2020). You are responsible to pay a $178 copayment for days 21-36 (September 15, 2020, to September 30, 2020). $178 (copayment) x 16 (SNF days) = $2,848. You have been asked to pay the total copayment amount of $2,848 for a SNF stay. A SNF stay falls within the SNF 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 waive the copayment for a SNF stay provided from August 26, 2020, to October 1, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 71046.

You asked the Plan to pay for the x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.

Review of the file shows that the x-ray services were billed with diagnosis code Z11.1 (Encounter for screening for respiratory tuberculosis). This means that the x-ray services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 71046.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for CxBladder testing provided on September 25, 2020.
You asked the Plan to pay for CxBladder test. You say that this testing is eligible for payment as long as the service meets the medical necessity guidelines. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this is not an approved test with the Medicare contractor.
The Plan must follow Medicare rules. Medicare rules say that CxBladder testing code 0013M is not covered by Medicare for date of service September 25, 2020. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CxBladder test have not been met. Therefore, we decided that the Plan does not have to pay for CxBladder testing provided on September 25, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the injection services provided on October 29, 2020.
You asked the Plan to pay for the services provided. You say that you believed this to be the common and
accepted treatment of your condition. The Plan denied your request. The Plan says that the injections you
received are not within the standard of care for your condition.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract
provider are considered approved by the plan unless notice is provided that the services will not be covered.
The Plan follows these rules.
The services at issue in this appeal were provided by a contract provider. The file does not show that the Plan
provided notice that the services provided would not be covered. Under Medicare rules, this means the services
provided is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the injection
services provided on October 29, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the deluxe frames (V2025) and progressive lens, (V2781) purchased December 7, 2020 by an out of network provider.
You asked the Plan to pay for the eyeglasses. You say that after pricing eyeglass frames and lenses at several in-network providers, you decided to purchase from this provider. The difference in price for essentially the same glasses was significant. The Plan denied your request. The Plan says You must use an in-network provider for routine coverage including routine exam, retinal imaging and eyewear allowance.
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 these services when the services are provided with an in network provider.
We looked at the file and the Plan's rules. You must use an in-network provider for routine coverage including routine exam, retinal imaging and eyewear allowance. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the deluxe frames (V2025) and progressive lens, (V2781) purchased December 7, 2020 by an out of network provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care.

You asked the Plan to waive the copayment for emergency care. You say that urgent care visits are covered under your policy and 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 $90 copayment for emergency care.

You have been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency 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 waive the copayment for emergency care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit provided on October 27,
2020.
You asked the Plan to pay for the domiciliary or rest home visit. 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 a domiciliary or rest home visit provided on October 27, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nyvepria.

You asked the Plan to pre-approve Nyvepria. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested drug.

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 Nyvepria. Our reviewer says that the documentation does not support that the enrollee meets criteria for the requested drug. Our physician reviewer found the enrollee has stage 4 lung cancer, is receiving chemotherapy treatment and requires treatment for prevention of febrile neutropenia. The documentation does not support that the enrollee has tried and failed Neulasta (pegfilgrastim), Fulphila (pegfilgrastim-jmdb), Udenyca (pegfilgrastim-cbqv) or Ziextenzo (pegfilgrastim-bmez). The documentation does not support any indication that the plan's 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 Nyvepria have not been met. Therefore, we decided that the Plan does not have to pre-approve Nyvepria.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transport from residence to dialysis.

You asked the Plan to pay for the non-emergent ambulance transport. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the enrollee appears to be able to sit in a wheelchair or recliner therefore alternatives to transport may include a wheelchair van or a private vehicle.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.

We looked at the file and Medicare rules. The record shows the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. The enrollee could have been safely transported by another type of vehicle. You did not request prior authorization. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transport from residence to dialysis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate lower denture (D5140).

You asked the Plan to pay for the dental item. You say that you called the plan to see if the provider was in network. You say that you were advised that the provider was in network. You say that if the plan representative had not okayed the procedure, then you would not have had it done. You say that you thought dentures were covered. You also say that you are disappointed with the Plan's coverage. The Plan denied your request. The Plan says immediate lower denture is not listed as a covered item. The Plan says that there was no discussion of any dental services or benefits in your call to the 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, 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 immediate lower denture (D5140).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for injections provided by a participating provider.

You asked the Plan to waive the copayment for an injection. You say that this copayment is way too high. The Plan denied your request. The Plan says the correct copayment 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 $250 copayment for outpatient surgery/in-network/surgical center.

You have been asked to pay a $250 copayment for each injection. The total amount you are being asked to pay is $750 ($250 x 3 injections = $750). An injection falls within the outpatient surgery/in-network/surgical center 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 injections provided by a participating provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc.

You asked the Plan to pre-approve Synvisc. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Synvisc is only covered for certain indications.

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 Synvisc. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee has a diagnosis of bilateral osteoarthritis of the knees and has failed treatment with steroids. There is no documentation that the enrollee's pain is affecting activities of daily living, how long the enrollee has tried and failed conservative treatment, and no information that the clinical diagnosis is supported by radiographic evidence of osteoarthritis. The documentation does not show that the enrollee has failed at least three months of conservative therapy. Therefore, the enrollee does not meet criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the self-administered drugs provided in an outpatient setting.

You asked the Plan to reimburse you for the self-administered drugs. You say that the drugs should be covered. You say that these drugs were received as part of your approved knee surgery. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to reimburse you for the self-administered drugs provided in an outpatient setting.

Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Avelumab.

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 that the services are not medically necessary.

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 these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has metastatic non-clear cell renal cell carcinoma. Avelumab is FDA approved for the first-line treatment of advanced renal cell carcinoma (in combination with Axitinib). The enrollee does not appear to have received prior therapy. Axitinib is being approved separately. The service is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-approve Avelumab.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on March 4, 2020.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a routine colonoscopy and 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 $395 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The record show that you received a colonoscopy on March 4, 2020. Due to the diagnostic codes submitted with the claim, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $395 copayment. You have been asked to pay a $395 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy provided on March 4, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiovascular risk assessment.

You asked the Plan to pay for the cardiovascular risk assessment. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular risk assessment testing except the basic lipid panel for symptomatic patients with suspected or documented cardiovascular disease.

The Plan must follow Medicare rules. Medicare rules say that a claim that is submitted for Cardiovascular Disease Screening shall be submitted with CPT codes 80061, 82465, 83718 or 84478.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cardiovascular risk assessment have not been met. Specifically, this panel is not a Medicare covered benefit. Therefore, we decided that the Plan does not have to pay for the cardiovascular risk assessment.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the bilateral suprascapular peripheral nerve stimulator insertion provided on June 19, 2020.
You asked the Plan to pay for the nerve stimulator insertion. The Plan denied your request. The Plan says this 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 pay for the nerve stimulator insertion. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is limited published peer-reviewed literature that shows the request to be fully effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for bilateral suprascapular peripheral nerve stimulator insertion on is not medically reasonable or 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 the nerve stimulator insertion have not been met. Therefore, we decided that the Plan does not have to pay for the bilateral suprascapular peripheral nerve stimulator insertion provided on June 19, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the dental services (D0220, D0120, D1110, D0274, D3310, D2950, D2392) provided on September 10, 2020, and September 15, 2020.
You asked the Plan to pay an additional amount for the dental services. You say that misunderstood what the charges would be. The Plan denied your request. The Plan says the claims processed correctly according to your 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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of dental services have not been met. Specifically, services were provided by an out-of-network provider. The Plan has contracted providers available to provide these services. We found no exception that would require the Plan to pay an additional amount for these services. Therefore, we decided that the Plan does not have to pay an additional amount for the dental services (D0220, D0120, D1110, D0274, D3310, D2950, D2392) provided on September 10, 2020, and September 15, 2020.