Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay.
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you were not admitted
to the hospital and therefore should not have to pay. The Plan denied your request. The Plan says the medical
record reflects that you were admitted for inpatient care and therefore the correct copayment amount was
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 $375
copayment for inpatient hospital care.
You have been asked to pay $375 copayment for the inpatient hospital stay. Your 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
the inpatient hospital stay.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not haveto waive the copayment for an ambulance trip provided by a participating provider on August 12, 2020.You asked the Plan to waive the copayment for an ambulance trip. You say that you do not agree with this copayment. You say that the ambulance wasn't operating at 100% and you should not be penalized for that. 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 ambulance services/in-network. You have been asked to pay a $250 copayment for an ambulance trip. An ambulance trip falls within the ambulance services/in-network benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore,we decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on August 12, 2020. We note your complaint about the ambulance not working correctly. Your complaint is a grievance that must be answered by the health 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 forintraoral-complete series x-rays (D0210) provided August 31, 2020.You asked the Plan to pay forthe dental services. You say that the x-rays were necessary because you switched dental offices and the new office required x-rays.The Plan denied your request. The Plan says this service exceeds the benefit frequency limitations. However a payment has been made to cover the bitewing x-ray portion of the full mouth series.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. This service is allowed once every 5 years. The records show this service was provided March 12, 2018. The plan did however approve payment to cover the bitewing x-ray portion of the full mouth series.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 forintraoral-complete series x-rays (D0210) provided August 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe panel genetic testing provided on July 14, 2020.You asked the Plan to pre-approvethe panel genetic testing. You say that you would like reconsideration because this testing was medically necessary.The Plan denied your request. The Plan says this testing was 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 the panel genetic testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found National Comprehensive Cancer Network (NCCN) prostate cancer guidelines recommend offering genetic testing to men with a personal history of high-or very high-risk regional or metastatic prostate cancer, or localized disease with intraductal histology, as well as a family history of high-risk germline mutations, or to those with a strong family history of cancer. There is no documentation that this member meets this criteria as his prostate cancer was 3 years ago and treated with IMRT.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 panel genetic testing have not been met.Therefore, we decided that the Plan does not have to pre-approvethe panel genetic testing provided on July 14, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveKetamine infusion (J2250).You asked the Plan to pre-approveKetamine infusion (J2250). You say that you get pain relief from the infusion.The Plan denied your request. The Plan says there is insufficient peer reviewed scientific literature that demonstrates this therapy is effective.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 Ketamine infusion (J2250). Our reviewer says that the drug is not reasonable or medically necessary. Our physician reviewer found there is insufficient peer-reviewed scientific literature that demonstrates that this therapy is effective. As such, a Ketamine infusion is considered experimental or investigative and not medically necessary. The review has determined that the documentation does not support that Ketamine is medically reasonable or necessary for the patient. The documentation does not support that the Ketamine infusion is safe and effective for the patient.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ketamine infusion (J2250) have not been met.Therefore, we decided that the Plan does not have to pre-approveKetamine infusion (J2250)
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forurography (74420) provided on August 21, 2020.You asked the Plan to pay forthe urography. You say that you would like reconsideration because this service was billed with the correct place of service code.The Plan denied your request. The Plan says this claim was billed with an outpatient place of service code but the member was inpatient on the billed date of service.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.We find that CPT code 74420is not supported in the record. Specifically, the record indicates that the member was registered inpatient on the billed date of service, but this claim was billed with an outpatient place of service code. Because the member was inpatient, it is necessary for the provider to bill the inpatient place of service code irrespective of the setting where the member received the face-to-face service. Based on this information, we decided that Medicare rules for coverage of the urography have not been met.Therefore, we decided that the Plan does not have to pay forurography (74420) provided on August 21, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay forthe emergency room services rendered on April 5, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later thanone calendar year after the date of service.The record shows that a claim for these services was not filed until September 15, 2020. A valid Waiver of Liability (WOL) was not received until October 19, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forthe emergency room services rendered on April 5, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveVelcade.You asked the Plan to pre-approveVelcade. 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 must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medicallyaccepted as safe and effective or appropriate for the particular use. 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 Velcade. Our reviewer says that the documentation does not support that the requested drug is medically reasonable or necessary. Our physician reviewer found the enrollee is receiving maintenance therapy with Bortezomib for Tp53 mutation with 4 cycles. The documentation does not support that the requested drug is FDA-approved as maintenance therapy. There are no major drug compendia or by clinical research that appears in a CMS-approved medical journal that support the requested drug for the enrollee's same induction regimens. 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 Velcade have not been met.Therefore, we decided that the Plan does not have to pre-approveVelcade.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that LTACH Admission is medically necessary.The Plan denied your request. The Plan says the enrollee can receive same services at the current level of care.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no required medical services identified that are available at the LTACH, thatare not available at the current health care setting being offered by the health plan.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 LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 14, 2020, by an out-of-network (OON) provider.You asked the Plan to pay forthese 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 had network providers available who could have provided 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 forthe medical services provided on August 14, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe filling for tooth # 6 and the unspecified preventive service provided on September 21, 2020.You asked the Plan to pay forthe dental services. You say that the filling should be covered. You say that this was an emergency. You say that it is only a temporary fix. You also say that you are on a fixed income and cannot pay that plus your copayments.The Plan denied your request. The Plan says 2 fillings are covered at 50% when you receive them in network. The Plan says that you have already been reimbursed for 2 fillings. The Plan also saysthat in network providers receive a separate monthly stipend for the unspecified preventive service.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 frequency limit of 2 fillings per calendar year have been exceeded. The record shows that the Plan paid for an extraction that you received on January 20, 2020 and another extraction that you received on June 17, 2020, thus exhausting the benefit.Therefore, we decided that the Plan does not have to pay forthe filling for tooth # 6 and the unspecified preventive service provided on September 21, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility services provided to the enrollee on August 21, 2020. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says in all custodial scenarios, the out-of-network provider would be responsible for securing a 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 had network providers available who could have provided 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 subsequent nursing facility services provided to the enrollee on August 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for extracapsular cataract removal with
insertion of intraocular lens prosthesis (66984) injection, midazolam hydrochloride (J2250) Posterior chamber
intraocular lens (V2632) provided December 2, 2019 to December 16, 2019.
You asked the Plan to waive the copayment for the cataract surgeries. You say that you were assured by your
insurance that this was totally covered. If the Insurance does not cover, it will probably take you 5 years to pay
if off in payments. The Plan denied your request. The Plan says this claim was processed and the correct
copayment was applied per the Evidence of Coverage.
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 $275
copay for outpatient hospital services.
You have been asked to pay $550 for the cataract surgeries. The cataract surgeries fall 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 extracapsular cataract removal with insertion of
intraocular lens prosthesis (66984) injection, midazolam hydrochloride (J2250) Posterior chamber intraocular
lens (V2632) provided December 2, 2019 to December 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve knee arthroscopy/surgery (29881). You asked the Plan to pre-approve knee arthroscopy/surgery. You say that the service is medically necessary. The Plan denied your request. The Plan says the service 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 knee arthroscopy/surgery. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found current evidence based medical guideline criteria have not been met. Mechanical symptoms are not documented and there is no documentation indicating a trial and failure of recent conservative care measures for the left knee. Therefore, the requested knee arthroscopy with meniscectomy 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 knee arthroscopy/surgery have not been met. Specifically, the service is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve knee arthroscopy/surgery (29881).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home exercise equipment provided to the enrollee on July 14, 2020. You asked the Plan to pay for home exercise equipment. You say that the date range is arbitrary; the pandemic started in March and the equipment was purchased after that. The Plan denied your request. The Plan says, based on the review of the additional information received, it was determined that the exercise equipment was not a covered benefit at the time of purchase. The Plan extended the wellness allowance to cover equipment purchased between October 1, 2020 - December 31, 2020. The exercise equipment was purchased on July 14, 2020, before the policy went into effect. Therefore, we are unable to approve your request.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home exercise equipment have not been met. Therefore, we decided that the Plan does not have to pay for home exercise equipment provided to the enrollee on July 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe pathology report and surgical pathology services received on August 5, 2020 to August 11, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe pathology report and surgical pathology services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services received are not a covered benefit when provided by an OON provider.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 had network providers available who could have provided 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 forthe pathology report and surgical pathology services received on August 5, 2020 to August 11, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea series of Gelsyn-3 knee injections.You asked the Plan to pre-approvea series of Gelsyn-3 knee injections. You say that the enrollee has improvement and pain relief with this drug.The Plan denied your request. The Plan says it has not been six months since the last series.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 
We looked at the file and Medicare rules. The last series was July 22, 2020 and there is no record of significant improvement in pain and function. Based on this information, we decided that Medicare rules for coverage of a seriesof Gelsyn-3 knee injections have not been met.Therefore, we decided that the Plan does not have to pre-approvea series of Gelsyn-3 knee injections
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the co payment for the inpatient hospital services rendered.

You asked the Plan to waive the co payment for these services. You say that you were approved to not owe more than 25 percent.The Plan denied your request. The Plan says the co payment was applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co payments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $395 co payment per dayfor days 1-4 for Medicare-covered hospital care. 

Review of the file shows that the enrollee received inpatient hospital services. The enrollee has been asked to pay a $395 co payment per day for days 1-4 for these services, for a total of $1,580. These services fall within the Medicare-covered hospital care 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 c opayment for the inpatient hospital services rendered.