Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the facet joint injection provided on September 2, 2020.
You asked the Plan to waive the copayment for the facet joint injection. You say that you normally pay a $40 copayment to see this provider. You say that you would not have had this done if you knew there was going to be a different 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 for Medicare covered surgical services in an outpatient hospital setting.
You have been asked to pay a $250 copayment for the facet joint injection. The facet joint injection falls within the "Outpatient hospital services" benefit category. The facet joint injection is considered a surgical service that was billed by the hospital. 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 facet joint injection provided on September 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3 injections.
You asked the Plan to pre-approve the Gelsyn-3 injections. You say that this medication is necessary. The Plan denied your request. The Plan says there is no indication our preferred agent(s) would likely be less effective, and/or cause adverse effects for the member.
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 Gelsyn-3 injections. Our reviewer says that the requested drug is not considered reasonable and necessary based on step therapy criteria. Our physician reviewer found the Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely 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 Gelsyn-3 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3 injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services.

You asked the Plan to pre-approve the skilled nursing services.. You say that the skilled nursing services are necessary. The Plan denied your request. The Plan says the enrollee does not meet coverage criteria.

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 the skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 the skilled nursing services. have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory test provided by an out-of-network provider on March 5, 2020.
You asked the Plan to pay for the laboratory test. You say that you are appealing the claim with medical records for further claim processing. You say that the claim should be reprocessed. The Plan denied your request. The Plan says prior authorization was required but 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 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 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 the laboratory test provided by an out-of-network provider on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an intracept procedure.
You asked the Plan to pre-approve the intracept procedure. You say that the enrollee has tried and failed conservative treatment without relief. You say that the requested procedure is needed for the enrollee's quality of life and has been shown to be safe, efficacious and effective. The Plan denied your request. The Plan says the requested services are not reasonable and medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the intracept procedure. Our reviewer says that the intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low back pain. She has multi-level spinal stenosis. She is taking Gabapentin for pain. She had tried physical therapy, but it didn't help. She has had prior spinal injections and radio frequency ablation (RFA) but these also did not help. The requested intracept procedure is experimental/ investigational at this point.
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 intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an intracept procedure.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the implantable joint device provided on May 27, 2020 to May 28, 2020.
You asked the Plan to waive the coinsurance for the implantable joint device. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received an implantable joint device on the dates of service at issue in this appeal. The Plan says that the correct coinsurance 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 Prosthetic devices and related supplies. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an implantable joint device on May 27, 2020 to May 28, 2020 on an outpatient basis. You have been asked to pay a 20% coinsurance for the implantable joint device, totaling $2847.92.
The implantable joint device 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 implantable joint device provided on May 27, 2020 to May 28, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery at an ambulatory surgical center provided on November 5, 2020, and November 19, 2020.
You asked the Plan to waive the copayment for the services. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2020 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received outpatient surgery at an ambulatory surgical center provided on
November 5, 2020, and November 19, 2020. You were asked to pay a $245 copayment per date of service for the surgical services. Your 2020 EOC states that enrollees must pay a $245 copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, including but not limited to hospital or other facility charges and physician or surgical charges. 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 outpatient surgery at an ambulatory surgical center provided on November 5, 2020, and November 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Nucala.

You asked the Plan to pre-approve a tier exception for Nucala. You say that the exception is needed. The Plan denied your request. The Plan says the drug does not qualify for tier exceptions.

The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a tier exception for Nucala have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Nucala.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve a skilled nursing facility admission. You say that denying SNF services will
significantly impair your ability to make a full recovery. The Plan denied your request. The Plan says you do
not meet criteria for coverage of a SNF admission.
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 a skilled nursing facility admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The beneficiary does not require skilled nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a skilled nursing facility admission. have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility services.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment for the office visit provided on December 12, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you have received many flu shots and vaccinations from the pharmacy over the years with no office charge. You say that you did not request or receive any other treatments and the specialist copayment should be removed. The Plan denied your request. The Plan says that the specialist 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 does not say in clear and accurate terms how much you should expect to pay for an office visit provided by a nurse practitioner at a walk-in retail health clinic. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $45 copayment for this office visit. A walk-in retail health clinic is not considered a specialist's office and a nurse practitioner is not considered a specialist. The Plan contract does not clearly say how much enrollees must pay for an office visit provided by a nurse practitioner at a walk-in retail health clinic. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayment for the office visit provided on December 12, 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: 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 would be best served by IRF care. The Plan denied your request. The Plan says the enrollee does not require intensive rehabilitation services to meet her needs.
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 complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was
admitted for fever, weakness, and lower extremity cellulitis. Medical conditions are stable. There are no complex nursing or rehabilitation needs. The patient does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. 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: Lab
Decision: Favorable

We decided that the Plan has to pay for lab work provided by an out-of-network provider on January 22, 2021.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says that prior authorization was not obtained.
The Plan must follow Medicare rules. The rules say that a Cost plan must cover items or services if an enrollee: 1. Received the items or services under the direction or authorization of a plan physician; 2. Correctly identifies himself or herself as a member of that plan to the contract provider before receiving the items or services; and 3. Has not been informed that he or she is liable for the cost of such items or services. The enrollee was referred for lab work by the member's primary care physician. provider. The provider is a contract provider with the Plan. Therefore, we decided that the Plan has to pay for lab work provided by an out-of-network provider on January 22, 2021.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve surgical services to be provided by an OON provider. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan says there are in-network facilities available to you that can provide the surgical procedure being requested.
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 surgical services to be provided by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services.
You asked the Plan to pre-approve the skilled nursing services. You say that the enrollee requires the skilled nursing services. The Plan denied your request. The Plan says your request does not meet Medicare guidelines because you are receiving adequate and necessary intensive rehabilitation in the Inpatient Rehabilitation Facility.
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 the skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found this enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. The enrollee does not require skilled nursing or therapy services on a daily basis. Therefore, the enrollee does not meet Medicare coverage criteria. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.
You asked the Plan to pre-approve a CPAP device. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that a CPAP device is covered when specific criteria are met. 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 a CPAP device. Our reviewer says that the item is not medically necessary. Our physician reviewer found the documentation does not support that the enrollee has had a repeat sleep test in a facility-based setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a CPAP device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous positive airway pressure (CPAP) device.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the pembrolizumab injection provided on May 17, 2019.
You asked the Plan to waive the coinsurance for the pembrolizumab injection. You say that your explanation of benefits shows your share is $0. You say that you have been unjustly charged and the cost should be waived. 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 each Medicare-Part B drug.
You have been asked to pay $237.86, which is 20% of the allowed amount for the pembrolizumab injection. The allowed amount is $1,189.29 (20% x $1,189.29 = $237.86). The pembrolizumab 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 pembrolizumab injection provided on May 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing: targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (CPT code 81455) provided to the enrollee on November 6, 2020.
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. As Comprehensive Genomic Profile (CGP) testing is not defined as a targeted panel by MolDX; and it is a test not currently satisfactorily described by any existing CPT code; to report a CGP, service providers should use CPT code 81479 (used for the entire bundled multi-test panel) at this time, in addition to the approved DEX Z-CodeTM entered adjacent in the comment/narrative field for the test; not unbundled to separate codes. Therefore, we decided that the Plan does not have to pay for Comprehensive Genomic Profile (CGP) testing: targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes (CPT code 81455) provided to the enrollee on November 6, 2020.