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

We decided that the Plan does not have to waive the copayment for the incision and drainage of cyst of eye (68020) provided March 3, 2021.

You asked the Plan to waive the copayment for the incision and drainage of cyst of eye. You say that you would like this copayment waived because you did not receive the services in question. The Plan denied your request. The Plan says the copayment has processed correctly in this case.

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 $45 copayment for physician/practitioner services in a specialist's office. 

You have been asked to pay a $45 copayment for the incision and drainage of cyst of eye. In this case, the medical records received support that this service was performed.

This service falls within the physician/practitioner services in a specialist's office 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 incision and drainage of cyst of eye (68020) provided March 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shoulder evaluation to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve an OON shoulder evaluation. You say that you believed this would be 
covered when you signed up for this Plan. The Plan denied your request. The Plan says this is available in-
network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a shoulder evaluation to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.

You asked the Plan to pre-approve foot orthotics. You say that you do not know why these shoes were denied your physician order these shoes. The Plan denied your request. The Plan says this item is not a covered benefit.

Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. 

Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee is not able to take care of themselves, are getting therapy and currently unable to go home. The Plan denied your request. The Plan says the stay is not medically necessary.

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 rules to 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 there is no documentation provided indicating medical necessity for the requested LTACH services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to further pay for the vacuum drainage collection unit and tubing kit (A7048) provided October 30, 2020.

You asked the Plan to further pay for the vacuum drainage collection unit and tubing kit. You say that you believe the enrollee had already hit the out-of-pocket maximum and should not be charged for this service. The Plan denied your request. The Plan says the claim processed correctly in this case.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a 20% coinsurance for durable medical equipment.

The enrollee has been asked to pay a 20% coinsurance for the vacuum drainage collection unit and tubing kit. In this case, you had not yet met the out-of-pocket maximum of $3,700. Therefore, you are still charged a coinsurance at this time. This service falls within the durable medical equipment 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 further pay for the vacuum drainage collection unit and tubing kit (A7048) provided October 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve pneumatic compression device. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this provider is out-of-network with the Plan and authorization was not obtained.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, Pembrolizumab, Dexamethasone Sodium Phosphate, Fosaprepitant, Vitamin B-12 Cyanocobalamin, and Palonosetron.
You asked the Plan to pre-approve the requested drug regimen. You say that this request is medically necessary and reasonable for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted 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 the requested drug regimen. Our reviewer says that the requested drug regimen is not medically reasonable and necessary. Our physician reviewer found that the enrollee has been diagnosed with stage IIIa non-small cell lung cancer in 2019. In this case, the requested drug regimen is not FDA-approved for the enrollee's condition as they have progressed while on prior immunotherapy. In addition, the use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. 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 requested drug regimen have not been met. Therefore, we decided that the Plan does not have to pre-approve Carboplatin, Pemetrexed, Pembrolizumab, Dexamethasone Sodium Phosphate, Fosaprepitant, Vitamin B-12 Cyanocobalamin, and Palonosetron.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 rules to 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 patient appears to be worsening and not stable enough for transfer at this time and can safely receive treatment at the current facility until more stable. The patient does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the patient requires that are not already available and covered at the current facility. Therefore, this request for LTACH will be considered not medically necessary at this time. Transfer may be considered when the patient is more stable and when treatment is completed. 

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-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on March 22, 2021.

You asked the Plan to pay for the dental services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the dental services provided are not covered under the Plan's supplemental dental benefit.

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 dental services provided are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental services provided on March 22, 2021.

Your questions about the imaging services you received is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care provided to the enrollee 
from August 6, 2021, forward. 
 
You asked the Plan to pre-approve inpatient mental health care. You say that the doctor attempted to call the 
number to complete the peer to peer and was on hold for over a hour, due to that, the peer was not completed. 
The Plan denied your request. The Plan says the stay is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment. 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 inpatient mental health care. Our 
physician reviewer found this enrollee does not meet the criteria for continued acute inpatient mental health 
treatment for the dates in question of August 6, 2021, forward as this enrollee was not shown to be a danger to 
themself or others. The enrollee was not showing any auditory or visual hallucinations and was 
cooperative/compliant with treatment. This enrollee was not showing any aggressive behaviors, or any 
treatment required for acute threats of safety. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve inpatient mental health care provided to the enrollee from August 6, 2021, 
forward.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is not medically necessary. The Plan 
denied your request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section 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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found that the enrollee does not have documented 
skilled nursing needs. In addition, the enrollee does not have documented skilled therapy needs. Daily skilled 
services are not required to establish a maintenance program or to prevent deterioration of the enrollee's 
condition. The enrollee's care needs at this point, can be provided at a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve admission to a skilled nursing facility (SNF)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Octagam 10% intravenous immune globulin (IVIG) administration in the home.
You asked the Plan to pre-approve the Octagam 10% IVIG administration in the home. The Plan denied your request. The Plan says drugs administered/injected in the home, without the use of durable medical equipment, are covered under Part D.
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 Octagam 10% intravenous immune globulin (IVIG) administration in the home.
Benefits for the Octagam 10% IVIG administration in the home 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient surgery provided on November 7, 2019 and January 8, 2020 and the MRI provided on January 21, 2020.

You asked the Plan to waive the cost share for the outpatient surgery and MRI. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request.

The Plan denied your request. The Plan says you received outpatient surgery and an MRI on the dates of service at issue in this appeal. The Plan says that the correct cost share has applied per your contract with the Plan.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for all other Outpatient Services including observation and outpatient surgical services not provided in an Ambulatory Surgical Center in 2019. Your contract with the Plan clearly says that you must pay a $225 copayment for all other Outpatient Services not provided in an Ambulatory Surgical Center in 2020. Your contract with the Plan clearly says that you must pay a $150 copayment for all other diagnostic procedures and tests in 2020.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received outpatient surgery on November 7, 2019 in an outpatient hospital setting. You have been asked to pay a 20% coinsurance for the outpatient surgery, totaling $719.39. The file shows that you also had outpatient surgery on January 8, 2020 in an outpatient hospital setting. For this surgery you have been asked to pay a $225 copayment for the 2020 benefit year. The outpatient surgery services fall within the Outpatient surgery benefit category. The file also shows that you received an MRI on January 21, 2020. You have been asked to pay a $150 copayment for the MRI. The MRI falls within the Outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amounts 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 cost share for the outpatient surgery provided on November 7, 2019 and January 8, 2020 and the MRI provided on January 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on April 28, 2021.

You asked the Plan to pay for the shingles vaccine. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the shingles vaccine is not covered under your Medicare Part B benefit.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the shingles vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on April 28, 2021.

Benefits for the shingles vaccine 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for additional routine transportation trips.

You asked the Plan to provide coverage for additional routine transportation trips. You say that you have been very sick, and you need additional trips to get to your doctor appointments. You say you have been dizzy and passing out and you cannot drive due to your condition. The Plan denied your request. The Plan says your benefit does not allow for more than 10 one-way trips per year.

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 10 one-way trips per year.

We looked at your request, the records in the case file, and the rules. The file shows that you have used all 10 one-way trips this year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to provide coverage for additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the post removal (D2955) and retreatment of previous root canal therapy (D3347).

You asked the Plan to pre-approve the post removal (D2955) and retreatment of previous root canal therapy (D3347). You say that the tooth needs to be removed as soon as possible. The Plan denied your request. The Plan says the services are not covered 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.

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 pre-approve the post removal (D2955) and retreatment of previous root canal therapy (D3347).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the office consultation. You say that you have exhausted all your options under your current Plan's network of providers. The Plan denied your request. The Plan says the provider is out-of-network.
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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The provider at issue in this case is not a network provider with the Plan. 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 office consultation. Our reviewer says that the service is not medically necessary. Our physician reviewer found you are currently being treated by a multi-disciplinary team at a tertiary care center and there is no unique therapy that is offered by this out-of-network provider.
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 office consultation have not been met. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve the office consultation. Therefore, we decided that the Plan does not have to pre-approve the office consultation to be provided by an out-of-network (OON) provider.