Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the positive airway pressure device supplies provided on March 24, 2020.
You asked the Plan to waive the coinsurance for the positive airway pressure device supplies. You say that you should not be responsible for the coinsurance because this equipment was not for you. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for durable medical equipment from an in-network durable medical equipment provider. You have been asked to pay $40.32 which is 20% of the allowed amount for the positive airway pressure device supplies. The allowed amount is $161.27. ($161.27 x 20% = $40.32). The positive airway pressure device supplies fall within the "Durable medical equipment (DME) and related supplies" benefit category. The record shows you have been receiving the durable medical supplies since 2019.
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 positive airway pressure device supplies provided on March 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the denosumab injection and office visit provided on March 23, 2020.
You asked the Plan to waive the cost for the denosumab injection and office visit. You say that you were informed you would have no patient responsibility. You say that you shouldn't have to pay. The Plan denied your request. The Plan says the cost share 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 20% coinsurance for Medicare Part B prescription drugs and chemotherapy drugs and a $20 copayment per visit to a specialist. You have been asked to pay a total of $251.34 for the denosumab injection and office visit.
Service
Allowed Amount
Standard Cost Share
Member Liability
Denosumab Injection
$1,156.68
20%
$231.34
Office Visit
$107.29
$20
$20
TOTAL:
$251.34
The denosumab injection falls within the "Medicare Part B prescription drugs" benefit category. The office visit 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 cost for the denosumab injection and office visit provided on March 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that TMS may be covered if prescribed and administered by a licensed physician who is knowledgeable in the use of repetitive transcranial magnetic stimulation. Outpatient rTMS may be indicated for patients with DSM-V defined Major Depressive Disorder who have failed to benefit from initial treatment of their depression. Failure must be documented by a trial of an evidence-based psychotherapy known to be effective in the treatment of MDD of an adequate frequency and duration without significant improvement in depressive symptoms as documented by standardized rating scales that reliably measure depressive symptoms. The order for treatment (or retreatment) must be written by a psychiatrist (MD or DO) who has examined the patient, and reviewed the record. The physician must have experience in administering TMS therapy. You can find this information in the Local Coverage Determination (LCD): Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder (L34869).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 4 additional months of a BiPAP and humidifier.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says a compliance report meeting coverage criteria must be submitted for any further rental.
The Plan must follow Medicare rules. Medicare rules say that enrollees must be re-evaluated to establish the medical necessity of continued coverage by Medicare beyond the first three months. The file shows that 7 months of BiPAP and humidifier services were requested. The Plan has agreed to pre-approve 3 months of coverage. We looked at the file and Medicare rules. The rules say that Medicare will not continue coverage for the fourth and succeeding months of therapy until a re-evaluation has been completed. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve 4 additional months of a BiPAP and humidifier.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa injections.
You asked the Plan to pre-approve the Euflexxa injections. The Plan denied your request. The Plan says the
information submitted does not meet the Plan's medical necessity guidelines for coverage. The Plan also says
that documentation was not received supporting the medical necessity for a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the Euflexxa injections. Our reviewer
says that Euflexxa does not meet the Plan's coverage criteria. Our physician reviewer found the enrollee has not
tried and failed the required drugs, Orthovisc and Monovisc. Our reviewer also found that there is no
documentation provided indicating that the Plan's required drugs are likely to be less effective and/or likely
have adverse effects for the enrollee.
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 Euflexxa injections have not been met. Therefore, we decided that the Plan
does not have to pre-approve Euflexxa injections.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ondansetron.
You asked the Plan to pre-approve these services. You say that the enrollee needs the medication to prevent nausea and vomiting associated with radiotherapy. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 ondansetron.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve the extractions of tooth #'s 23 and 28.
You asked the Plan to pre-approve the extractions. You say that the enrollee is in pain and needs extractions.
The Plan denied your request. The Plan says that the x-rays need to show that the enrollee's gum would need to
be cut near the tooth, cut the tooth into pieces, or need to also remove some bone to be able to remove the
tooth. The Plan also says that the provided x-rays do not show this.
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. The Plan covers the
extractions when the services are medically necessary and reasonable.
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 extractions. Our reviewer says that
the extractions meet the Plan's coverage criteria. Our physician reviewer found due to the weakened nature of
the crowns of tooth #'s 23 and 28, and due to caries and the long roots encased in bone, surgical extractions
meet the criteria for coverage.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the extractions have been met. Therefore, we decided that the Plan has to preapprove
the extractions of tooth #'s 23 and 28.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the nutrition administration kit, nutrition
supply kit, nutrition solution and nutrition additives provided from February 11, 2020 through February 17,
2020.
You asked the Plan to waive the coinsurance for the nutrition administration kit, nutrition supply kit, nutrition
solution and nutrition additives. You say that you have never paid for parenteral nutrition before. You say that
you can't find verification that these are legitimate charges. The Plan denied your request. The Plan says the
coinsurance 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 20%
coinsurance for Medicare-covered prosthetic devices and related supplies.
You have been asked to pay a total of $635.40 for the nutrition administration kit, nutrition supply kit, nutrition
solution and nutrition additives.
The nutrition administration kit, nutrition supply kit, nutrition solution and nutrition additives falls within the
"Prosthetic devices 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 the nutrition administration kit, nutrition supply kit, nutrition solution and nutrition additives provided from
February 11, 2020 through February 17, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transports provided on March 2, 2020.
You asked the Plan to waive the copayment for the ambulance transports. You say that you never asked for an ambulance. You say that you will not pay this. 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 $225 copayment for Medicare-covered ambulance transport (one-way). You have been asked to pay a $225 copayment each ambulance transport. The total amount you owe is $450 ($225/transport x 2 transports = $450). The ambulance transports 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 the ambulance transports provided on March 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Wixela Inhub.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Wixela Inhub.
Benefits for these services 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee struggles to communicate, walk, eat, and use her dominant hand. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical status does not currently require intensive physician and nursing oversight only in an IRF. While the enrollee may benefit from multiple therapies such as physical and occupational therapy, the documentation does not support that the enrollee's functional status requires an 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the specialist office visit provided on December 10, 2019.
You asked the Plan to reduce the copayment for the specialist office visit. You say that you saw the nurse practitioner and believe you should pay the $10 copayment and not the $45 copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for each covered visit or consultation in an outpatient location with a specialist. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the nurse practitioner specializes in obstetrics and gynecology.
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 reduce the copayment for the specialist office visit provided on December 10, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a home health visit for blood collection (venipuncture).
You asked the Plan to pre-approve these services. You say that you have an upcoming doctor visit and are on a
stay at home order. The Plan denied your request. The Plan says the services are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that home health services are not covered for venipuncture
only.
We looked at the file and Medicare rules. Home health services are being requested for venipuncture only.
Based on this information, we decided that Medicare rules for coverage of these services have not been met.
Therefore, we decided that the Plan does not have to pre-approve a home health visit for blood collection
(venipuncture).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on January
28, 2020.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you were not aware of this
large coinsurance amount and not advised it would be this much when it was administered. You say you had
the same injection in 2018 with no charge. The Plan denied your request. The Plan says you have been charged
the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20%
coinsurance for Medicare Part B chemotherapy and non-chemotherapy prescription drugs.
You have been asked to pay $2,703.55 which is 20% of the allowed amount for the Part B injection. The
allowed amount is $13,517.76. ($13,517.76 x 20% = $2,703.55). The Part B injection falls within the
"Medicare Part B prescription drugs" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the coinsurance for the Part B injection provided on January 28, 2020.
Our decision is only about the 2020 service. If you have any questions about prior years billing, please contact
the plan directly.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Denosumab (Prolia).
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says the information
submitted does not meet the Plan's medical necessity guidelines for coverage.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve Prolia. Our reviewer says that Prolia
does not meet the Plan's coverage criteria. Our physician reviewer found the enrollee has not tried and failed
the required drug, Zoledronic Acid. There is no documentation indicating that the Plan's required drug would
likely be less effective and/or likely have adverse effects for the enrollee. Our reviewer also found that there is
no documentation indicating the enrollee has a history of osteoporosis-related fracture.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Denosumab (Prolia).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you need more physical therapy. The Plan denied your request. The Plan says the admission is not medically necessary.
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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the submitted records show that you were admitted to the hospital with Parkinson's disease, diabetes, atrial fibrillation (rapid heartbeat), and heart disease. You received oral medications and insulin and had stable vital signs. You received physical therapy in the hospital and need assistance with bed mobility and transfers. You are not able to walk on your own. You have no skilled nursing or skilled therapy needs. You do not need skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from March 20,
2020 through March 24, 2020.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were called back after
being discharged. You say that you shouldn't owe another copayment. 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 $250
copayment per in-network admission.
You have been asked to pay a $250 copayment for the inpatient stay. The inpatient stay falls within the
"Inpatient hospital care" benefit category. The records show that this was a separate admission. 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 March 20, 2020 through March 24,
2020.