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

We decided that the Plan does not have to waive the coinsurance for the Part B chemotherapy drugs and their administration provided from July 28, 2020, to August 25, 2020.

You asked the Plan to waive the coinsurance for the Part B chemotherapy drugs and its administration. You say that you would like the cost share waived. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing 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 each Medicare-covered chemotherapy drug and the administration of that drug. 

You have been asked to pay $2,342.46 coinsurance for the Part B chemotherapy drugs and their administration. The Part B chemotherapy drugs and its administration fall within the "Medicare Part B Prescription Drugs" benefit category. See chart below.

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 the Part B chemotherapy drugs and their administration provided from July 28, 2020, to August 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vision services to be provided by an out of network provider.

You asked the Plan to pre-approve vision services with an out of network provider. You say that you have been going to this doctor for 21 years and are comfortable with this provider.The Plan denied your request. The Plan says a participating provider can provide vision services.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approve vision services to be provided by an out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left GivMohr sling (E1399).

You asked the Plan to pre-approve a sling. You say that you are appealing the denial for a sling.The Plan denied your request. The Plan says soft slings do not meet the definition of durable medical equipment or prosthetic and orthotics and is not covered under the plan benefits.

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. Based on this information, we decided that Medicare rules for coverage of a sling have not been met.Therefore, we decided that the Plan does not have to pre-approve a left GivMohr sling (E1399).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second set of medical branch block injections.

You asked the Plan to pre-approve a second set of injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (64494). You say that the enrollee needs the blocks for pain relief.The Plan denied your request. The Plan says a second set of bilateral 2 level medial branch blocks is not appropriate until the response to the first set is documented.

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. Based on this information, we decided that Medicare rules for coverage of a second set of injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level (64493) and injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure) (64494) have not been met.Therefore, we decided that the Plan does not have to pre-approve a second set of medical branch block injections.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for dialysis services provided October 1, 2020 to October 31, 2020.

You asked the Plan to pay for the dialysis services. You say that the services were medically necessary.The Plan denied your request. The Plan says that there were network providers available.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The plan did not furnish a copy of the 2020 Evidence of Coverage to the IRE for review. Without the Evidence of Coverage, it cannot be determined what if any out-of-network benefits the enrollee had. The Evidence of Coverage was requested by the IRE in a request for information and it was not received.Therefore, we decided that the Plan has to pay for dialysis services provided October 1, 2020 to October 31, 2020.

If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rinvoq tablet, 15 mg.

You asked the Plan to pre-approve Rinvoq. You say that this drug is medically necessary.The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Rinvoq tablet, 15 mg.

Benefits for Rinvoq 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the consultation to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the consultation. You say that you would prefer to see the out of network provider for your symptoms. 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 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 the consultation to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing provided on December 16, 2020.

You asked the Plan to pay for the testing services. You say that the testing is a covered benefit.The Plan denied your request. The Plan says the enrollee does not meet the criteria.

The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is only covered under certain medical indications.

We looked at the file and Medicare rules. The records provided do not show that the enrollee has have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for a repeat biopsy due to persistent or elevated cancer-risk factors. Based on this information, we decided that Medicare rules for coverage of the testing services have not been met.Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing provided on December 16, 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 IRF care is medically necessary.The Plan denied your request. The Plan says rules for IRF care have 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 in the Medicare rules section.

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 patient was admitted to an acute care hospital for sepsis, gastrointestinal bleeding, and diverticulitis. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a therapeutic continuous glucose monitor system and supply allowance.

You asked the Plan to provide a therapeutic continuous glucose monitor (CGM) system and supply allowance. You say that the enrollee is not on daily insulin but needs a therapeutic continuous glucose monitor system.The Plan denied your request. The Plan says criteria is not met for a therapeutic continuous glucose monitor system and supply allowance.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor (CGM) system and supply allowance have not been met.Therefore, we decided that the Plan does not have to provide a therapeutic continuous glucose monitor system and supply allowance.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve TheraSkin wound treatment.

You asked the Plan to pre-approve TheraSkin. You say that this service is medically necessary.The Plan denied your request. The Plan says this is not a covered service.

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 TheraSkin. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the patient is a 71 year old diabetic who had a fall on January 25, 2021 with a large wound to the left upper extremity. TheraSkin is indicated for the treatment of chronic wounds that have failed to respond to the first line standard of conservative care. The documentation notes that the patient is still being treated for an infection is his upper extremity wound. The use of TheraSkin in this setting is not supported by the literature.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TheraSkin have not been met.Therefore, we decided that the Plan does not have to pre-approve TheraSkin wound treatment.
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 you would like reconsideration because the IRF admission is medically necessary.The Plan denied your request. The Plan says there is no need for physician supervision 3 times per week for ongoing management of any active or acute exacerbations of chronic medical conditions.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

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 member does not have any complex skilled nursing needs and there is no documented need for an intensive rehabilitation program.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forstrapping provided from January 2, 2020, to January 17, 2020.

You asked the Plan to waive the copayments for strapping. You say that you disagree with the surgery charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). 

Your contract with the Plan clearly says that you must pay a $250 copayment for outpatient surgery, including services provided at hospital outpatient facilities.You received strapping at an outpatient hospital facility from January 2, 2020, to January 17, 2020, for a total of 3 services. Therefore, you are responsible to pay a $250 copayment per each service. However, you are being asked to pay the total allowed amount of $407.50, which is less than the total copayment amount.

You have been asked to pay $407.50 for strapping. Strapping 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 strapping provided from January 2, 2020, to January 17, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy and needle insertion provided on March 26, 2020.

You asked the Plan to waive the copayment for the physical therapy and needle insertion. You say that you are being charged two copayments for physical therapy and dry needling.The Plan denied your request. The Plan says the copayments 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 $35 copayment per Medicare-covered visit of physical therapy, occupational therapy, and speech language therapy services and a $35 copayment per visit to a specialist.

You have been asked to pay a $35 copayment for the physical therapy and $29.09, which is less than the standard $35 copayment for the needle insertion. The physical therapy falls within the "Outpatient rehabilitation services" benefit category. The needle insertion falls within the "Physician/Practitioner services, including doctor's office visits" 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 physical therapy and needle insertion provided on March 26, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider on January 20, 2021.

You asked the Plan to pay for the laboratory services. You say that molecular testing was ordered as part of the patient's treatment plan and testing should be covered. You say that the denial is improper and contradicts policies.The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not authorized.

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 laboratory services provided by an out-of-network provider on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acupuncture services for treatment of neuropathy.

You asked the Plan to pre-approve acupuncture services. You say that there are no approved cures or treatment for neuropathy available through the plan. You really want to try acupuncture as a possible alternative to help slow or stop the progression of this condition.The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for acupuncture services.

The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. 

We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture for any condition other than chronic low back pain is not covered by Medicare.Therefore, we decided that the Plan does not have to pre-approve acupuncture services for treatment of neuropathy.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation -problem focused (D0140), and the panoramic radiographic image (D0330) received November 27, 2020.

You asked the Plan to pay for the limited oral evaluation -problem focused, and the panoramic radiographic image. You say that the requested services were necessary.The Plan denied your request. The Plan says when this claim was processed you had exhausted your $3,000 benefit maximum.

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 payment is in excess of that which is covered under this benefit. 

The Plan has submitted evidence that your $3,000 annual benefit maximum was exhausted prior to the date on which these claims were processed. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation -problem focused (D0140), and the panoramic radiographic image (D0330) received November 27, 2020.