Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3. 
 
You asked the Plan to pre-approve Gelsyn-3. You say that you are in pain, and it's hard to walk. The Plan denied your request. The Plan says you have not had previous treatment, contraindication, or intolerance to Orthovisc and Monovisc. 
 
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 Gelsyn-3. Our physician reviewer found that you have pain related to osteoarthritis of both knees, confirmed with x-rays and failed conservative treatment. The Plan requires a trial of drugs Orthovisc and Monovisc first before they will approve the requested drug, Gelsyn-3. The provided medical records do not indicate that you have tried and failed the required drugs. The provided medical records do not indicate that the Plan's required drugs would likely be less effective, or likely have adverse effects.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on January 30, 2020. You asked the Plan to waive the copayment for an EGD. You say that you were told that the enrollee would only owe a $25 copayment for the EGD. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $175 copayment for surgery services provided in an outpatient hospital facility. The enrollee received an EGD on January 30, 2020 at an outpatient hospital facility. An EGD is considered an outpatient surgical procedure. Therefore, they are responsible to pay the $175 copayment. The enrollee has been asked to pay a $175 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. 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 copayment for an EGD provided on January 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on February 14, 2020. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug. 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 20% coinsurance for Medicare Part B prescription drugs.  
 
You received a Medicare Part B drug on February 14, 2020. The allowed amount is $230.07 and 20% of that is $46.01.  
 
You have been asked to pay the total coinsurance amount of $46.01 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 Medicare Part B drug provided on February 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete mandibular denture and complete maxillary denture provided on February 4, 2020.
You asked the Plan to pay for the complete mandibular denture and complete maxillary denture. You say that you do not agree with the letter you received. The Plan denied your request. The Plan says the treating provider is not contracted with your Plan, and is not your Plan assigned dental office. The Plan also says that unless your Plan approves it, the Plan only covers services done by your assigned dentist.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered when they are received by anyone other than your assigned contract dentist. Therefore, we decided that the Plan does not have to pay for the complete mandibular denture and complete maxillary denture provided on February 4, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on January 3, 2020. 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 procedure code 97530 is not separately payable. The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 97530 and 97140. Code 97530 is a column II code with a modifier indicator of 1 when billed with column I code 97140. Code 97530 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the physical therapy services rendered on January 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chiropractic services (CPT 99212) provided from March 2, 2020, to March 10, 2020.You asked the Plan to payforthe 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 the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay forthe chiropractic services (CPT 99212) provided from March 2, 2020, to March 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit for a new patient (99203) provided on March 5, 2019. You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records show that this provider billed for March 05, 2020 procedure code 99203, Office or other outpatient visit for the evaluation and management of a new patient, under the same group practice and specialty identify by the same Tax Identification number, Taxonomy number and the National Provider Identifier number provided. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99203 is office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family. We find that CPT code 99203 is not supported in the record. Specifically, the record indicate that the Plan paid CPT code 99214 for an outpatient visit for the evaluation and management of an established patient to this provider for date of service, March 3, 2020. This shows that this member has received professional services from this provider within 3 years and is not a new patient. Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit for a new patient (99203) provided on March 5, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ambulance ride provided on July 30,
2019.
You asked the Plan to waive the deductible for the ambulance ride. You say that you were billed incorrectly as
an out-of-network ambulance. 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. Your
contract with the Plan says that there is a $500 deductible that applies towards each in- and out- of service area,
one-way Medicare-covered ambulance transport after your yearly deductible is met.
The ambulance ride you asked the Plan to waive the deductible for falls within the "Ambulance services"
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500
deductible that applies towards each in- and out- of service area, one-way Medicare-covered ambulance
transport after your yearly deductible is met. This cost sharing is a contractual obligation that had not been met
at the time the ambulance ride was received on July 30, 2019. Therefore, we decided that the Plan does not
have to waive the deductible for the ambulance ride provided on July 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased October 10, 2019. You asked the Plan to pay for the hearing aids. You say that the current allowed hearing benefits should be raised because it does not keep up with current prices. The Plan denied your request. The Plan says the claim processed correctly according to the plan 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). Your contract with the Plan clearly says the plan's maximum benefit is $1,000 per ear ($2,000) every 36 months for hearing aid. You are responsible for any amount above the maximum benefit.You have been asked to pay $6,900 for the hearing aids. The hearing aids falls within the Hearing 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 for hearing aids purchased October 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from February 24, 2020 to February 28, 2020.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you were transferred from another inpatient hospital facility and disagree with the second admission copayment. 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 $300 copayment per admission for inpatient hospital care. You had an inpatient hospital stay from February 24, 2020 to February 28, 2020. This is considered a new inpatient hospital admission. Therefore, you are responsible to pay the $300 copayment. You have been asked to pay a $300 copayment for an inpatient hospital stay. An inpatient hospital stay falls within the inpatient hospital 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 an inpatient hospital stay from February 24, 2020 to February 28, 2020.
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
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the documentation does not support that your nursing, medical and rehabilitation
needs require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While
you may benefit from continuing physical therapy (PT) and occupational therapy (OT), there is no evidence of
need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an
interdisciplinary approach to rehabilitation 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for inpatient surgery services provided on
February 4, 2020.
You asked the Plan to waive the deductible for inpatient surgery services. You say that your previous plan
didn't have a deductible. You say that it was not explained that you would have a deductible before the Plan
pays. The Plan denied your request. The Plan says the deductible applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your
contract with the Plan says that your deductible is $1,000. This is the amount you have to pay out-of-pocket
before we will pay our share for your covered medical services. Until you have paid the deductible amount,
you must pay the full cost for most of your covered services.
The item or service you asked the Plan to waive the deductible for falls within the "Inpatient hospital care"
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000
deductible applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met
at the time inpatient surgery services were received on February 4, 2020. Therefore, we decided that the Plan
does not have to waive the deductible for inpatient surgery services provided on February 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a home visit provided on December 17, 2019. You asked the Plan to pay for the 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 home visit provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on February 25, 2020. 
 
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent, 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 physician's services provided on February 25, 202
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on March 11, 2020. 
 
You asked the Plan to pay for the comprehensive oral evaluation and complete series of intraoral x-rays. You say that you went to this provider to get a quote for a procedure. You also say that you did not ask for anything to be done. The Plan denied your request. The Plan says the provider needed to complete an oral evaluation and take x-rays in order to properly diagnose, treat the issue, and to provide an accurate quote. The Plan also says that this claim has been processed correctly. 
 
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, oral exams are limited to up to 1 visit every six months. The record shows that you last received an oral exam on December 17, 2019, and your oral exams benefit had been exhausted for the time period. The Plan also says that you are allowed one full mouth x-ray every three years, which resulted in a $10 copayment for preventive dental services. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation and complete series of intraoral x-rays provided on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig you received on January 7, 2020. 
 
You asked the Plan to pay for the wig. You say that this is necessary. The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. 
 
In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is non-covered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. The associated sales tax is not medical in nature and is also non-covered. Therefore, we decided that the Plan does not have to pay for the wig you received on January 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided from January 6, 2020 to
January 16, 2020.
You asked the Plan to pay for the self-administered drugs. You say that the statement said the Plan was
denying self-administered medications. The Plan denied your request. The Plan says these are self-administered
drugs and are not Part B covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 pay for the self-administered drugs
provided from January 6, 2020 to January 16, 2020.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forOphthalmological services, medical examination and evaluation (92014) and fundus photography (92250) provided January 14, 2020.You asked the Plan to waive the copayment forthe vision services. You say that you are requesting reviewof the claim to ensure you were billed correctly.The Plan denied your request. The Plan says the correct copayment was applied according to the plan 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). Your contract with the Plan clearly says that you must pay $65 copayment for out of network specialists office for vision care. You have been asked to pay $65 copayment 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 waive the copayment forOphthalmological services, medical examination and evaluation (92014) and fundus photography (92250) provided January 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 6, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you 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 November 6, 2019.