Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation.
You asked the Plan to pre-approve additional transportation. You say that you have to travel a long distance for your doctors. The Plan denied your request. The Plan says transportation beyond the 12 one-way trips are not covered.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 12 one-way trips per year. We looked at your request, the records in the case file, and the rules. Once you have used 12 one-way trips, you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Skyrizi injections.
You asked the Plan to pre-approve Skyrizi. You say that the enrollee's treatment failure and considerable lack of improvement of plaques interfere with her daily life. The Plan denied your request. The Plan says the medication does not fall under the Part B benefit.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Skyrizi injections.
Benefits for Skyrizi 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 pay forthe dental services provided on November 26, 2018 by a non-contracted provider.You asked the Plan to pay forthe dental services. You say that it is your understanding that you have dental allowance of $450 per year.The Plan denied your request. The Plan says the services are not covered under Medicare or the Health Plan.Medicare generally does not cover dental services. The Plan follows the same rule.The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid for by Medicare. You did not purchase dental coverage as an optional supplemental benefit.Therefore, we decided that the Plan does not have to pay forthe dental services provided on November 26, 2018 by a non-contracted provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on January 28, 2020.
You asked the Plan to waive the copayment for ambulance services. You say that you could have had a friend pick you up. 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 $100 copayment for ambulance services. You have been asked to pay a $100 copayment for ambulance services. Ambulance services fall within the ambulance 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 waive the copayment for ambulance services provided on January 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 2, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed
service cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on January 30, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the billed
services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the
medical record, his or her intent that the test be performed.
We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab
requisition stating exactly which testing was to be performed. Based on this information, we decided that
Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan
does not have to pay for the drug testing services provided on January 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on May 17, 2019.
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the high 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 DME and related supplies. You received DME on May 17, 2019. The allowed mount is $1,386.17 and 20% of that is $277.23. You have been asked to pay the total coinsurance amount of $277.23 for DME. DME falls within the DME and related 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 coinsurance for DME provided on May 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Golimumab/Simponia Aria for the enrollee.You asked the Plan to pre-approve the drug. You say that this is medically necessary.The Plan denied your request. The Plan says the criteria has not been met.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 the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found Golimumab in combination with methotrexate is indicated for the treatment of moderately to severely active rheumatoid arthritis. There is no documentation that the enrollee is on methotrexate or has a contraindication or intolerance to it.We looked at this physician's review, the file, and Medicare rules.Based on this information, we decided that Medicare rules for coverage of the drug have not been met.Therefore, we decided that the Plan does not have to pre-approve Golimumab/Simponia Aria for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient admission for a surgical procedure.You asked the Plan to pre-approve an inpatient admission for a surgical procedure. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.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 an inpatient admission for a surgical procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific indication presented to support the medical necessity of full inpatient admission over observational care overnight. There is no evidence that the physician expected the enrollee's medically necessary treatment to span 2 midnights or more. Therefore, the requested inpatient admission for the approved left total knee arthroplasty would not be considered medically reasonable and necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an inpatient admission for a surgical procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve an inpatient admission for a surgical procedure.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for EGD's provided on January 23, 2020 and February 7, 2020.
You asked the Plan to waive the copayments for EGD's. You say that you disagree with the charges because they were used to check for cancer. 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 $350 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received EGD's on January 23, 2020 and February 7, 2020. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay a $350 copayment per each visit. The total amount you owe is: $700. You have been asked to pay the total copayment amount of $700 for EGD's. EGD's 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 copayments for EGD's provided on January 23, 2020 and February 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (20939).
You asked the Plan to pre-approve bone marrow aspiration for bone grafting. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
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 bone marrow aspiration for bone grafting. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for use in spinal fusion surgery. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration for bone grafting have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration for bone grafting (20939).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from April 14, 2019 through April 16, 2019.You asked the Plan to waive the copayment for the inpatient stay. You say that you thought you would be given medication and sent home. You say that you never requested to be admitted. The Plan denied your request. The Plan says the copayment applied 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). Your contract with the Plan clearly says that you must pay a $325 copayment per day for days 1 through 5 for in-network, covered hospital care.You have been asked to pay a $650 copayment for the inpatient stay. ($325/day x 2days = $650). The inpatient 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 stay provided from April 14, 2019 through April 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion or replacement of a permanent leadless pacemaker (33274) provided on December 30, 2019.
You asked the Plan to pay for the insertion or replacement of a permanent leadless pacemaker. You say that the medical records support this service. The Plan denied your request. The Plan says there is no documentation of an appropriate trial.
The Plan must follow Medicare rules. Medicare rules say that CMS covers leadless pacemakers when procedures are performed in Food and Drug Administration (FDA) approved studies. CMS also covers, in prospective longitudinal studies, leadless pacemakers that are used in accordance with the FDA approved label for devices that have either: an associated ongoing FDA approved post-approval study; or completed an FDA post-approval study. We looked at the file and Medicare rules. The records do not document that the enrollee is enrolled in a clinical trial or study as required by Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion or replacement of a permanent leadless pacemaker have not been met. Therefore, we decided that the Plan does not have to pay for the insertion or replacement of a permanent leadless pacemaker (33274) provided on December 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for wound debridement provided from November 11, 2019 to November 25, 2019. You asked the Plan to waive the copayments for wound debridement. You say that you disagree with the charges and feel that you should owe a specialist 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 members must pay a $350 copayment for outpatient surgery services provided in an outpatient hospital facility. You received wound debridement from November 11, 2019 to November 25, 2019 for a total of 3 visits. Wound debridement is considered an outpatient surgical procedure. Therefore, you are responsible to pay the total allowed amount of $846.65. You have been asked to pay the total copayment amount of $846.65 for wound debridement. Wound debridement 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 copayments for wound debridement provided from November 11, 2019 to November 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that the enrollee's pneumonia and pleural effusion makes her a high candidate for decompensation. The Plan denied your request. The Plan says the enrollee does not require skilled nursing or therapy services at this time.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 SNF services. Our physician reviewer found that from a nursing perspective, the enrollee had stable vital signs, and received oral medications. There are no identifiable skilled nursing service needs. Regarding rehab services, the enrollee did not receive or require any skilled therapy. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platform crutch (E0118).
You asked the Plan to pre-approve a platform crutch. You say that the requested item is 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. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the enrollee's medical records and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a platform crutch have not been met. Specifically, medical records were not provided. Without this documentation, medical necessity is not able to be established. Therefore, we decided that the Plan does not have to pre-approve a platform crutch (E0118).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 27, 2018.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal was 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 laboratory services rendered on November 27, 2018.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room visit on February 26, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment 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 a $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit 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 an Emergency Room visit on February 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 28, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on January 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye exam provided on January 28, 2020
You asked the Plan to waive the copayment for the eye exam. You say that you were told there would be no copayment. The Plan denied your request. The Plan says that the copayment was applied 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). Your contract with the Plan clearly says that you must pay a $30 copayment for exams to diagnose and treat diseases and conditions of the eye by an Ophthalmologist. You have been asked to pay a $30 copayment for the eye exam. The eye exam falls within the exams to diagnose and treat diseases and conditions of the eye by an Ophthalmologist 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 eye exam provided on January 28, 2020.