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

We decided that the Plan does not have to waive the copayment for lab services you received on April 1, 2021.
You asked the Plan to waive the copayment for the lab services. You say that you feel as though the lab services should be included in your annual physical. The Plan denied your request. The Plan says you were charged this copayment 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 $10 copayment for lab services in a primary care office or other non-specialist setting. You have been asked to pay a $10 copayment for the lab services. Your Evidence of Coverage explicitly states that annual physicals and annual wellness exams do not include lab tests. 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 lab services you received on April 1, 2021
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the SNF services are medically necessary. The Plan denied your request. The Plan says coverage criteria has 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 the SNF 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 stay in a skilled nursing facility setting. The enrollee's needs can be met 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for pain management services provided on March 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for pain management services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 pain management services provided on March 11,
2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Aflibercept (Eylea) for intravitreal injection.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says that multiple reports and studies in the scientific literature support the use of Bevacizumab in this case.

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 injection. Our reviewer says that the requested drug is medically reasonable or necessary. Our physician reviewer found the prescribing vitreoretinal surgeon indicates that the plan's required drug would likely be less effective, and/or is more 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 injection have been met. Therefore, we decided that the Plan has to pre-approve Aflibercept (Eylea) for intravitreal injection.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the dental cleaning (D1110) provided on
April 30, 2021, by an out-of-network provider.
You asked the Plan to waive the cost sharing for the dental cleaning. You say you do not understand why the
Plan is paying so little for the service and you have not had this issue before. You chose this provider because
they were highly recommended by friends and family and you are allowed to see providers out-of-network. The
Plan denied your request. The Plan says the provider in question is out-of-network, and the cost-sharing has
been applied correctly.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. 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 50% coinsurance for a prophylaxis (cleaning) received from an out-of-network provider.
Network dentists have agreed to provide services at a negotiated rate. If you see a network dentist, you cannot
be billed more than that rate for covered services. Benefits received out-of-network are subject to any innetwork
benefit maximums, limitations, and/or exclusions. You may be billed by the out-of-network provider
for any amount greater than the payment made by the Plan to the provider.
You have been asked to pay $103 for the dental cleaning received from an out-of-network provider. The
provider billed the Plan $121 for the service, and the Plan's maximum allowed charge for this service is $36.
This is the amount that an in-network provider would accept as full payment for the service, however out-ofnetwork
providers do not have this agreement with the Plan and are allowed to bill you for any amount greater
than this payment up to the amount they bill. In this case, this amount is $85 ($121 billed - $36 Plan's
maximum charge = $85). In addition, you are responsible for 50% coinsurance when you receive a dental
cleaning from an out-of-network provider. Coinsurance comes from the Plan's allowed amount, so you are
responsible for $18 ($36 x 50% coinsurance) as well as the billed difference for a total of $103. 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 sharing for the dental cleaning (D1110) provided on April 30, 2021, by an outof-
network provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services.
You asked the Plan to pre-approve SNF services. You say that you are not strong enough to go home. The Plan denied your request. The Plan says you do not require daily skilled nursing or therapy services on an inpatient basis.
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 services. Our physician reviewer found that you are at a standby assist level for ambulation, modified independent for bed mobility and transfers, and you are tolerating and oral diet. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near baseline. Therefore, an admission to a SNF is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission and services
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 288 tracheostomy cleaning brushes (A4626).
You asked the Plan to pre-approve an additional 288 tracheostomy cleaning brushes. You say that you sometimes need to use brushes more than twice a day. The Plan denied your request. The Plan says the requested quantity is not reasonable and necessary.
The Plan must follow Medicare rules. Medicare rules say that he maximum number of items/units of service that are usually reasonable and necessary of tracheostomy cleaning brushes (A4626) are 2 per month. The explanation for use of a greater quantity of supplies than the amounts listed must be clearly documented in the beneficiary's medical record. We looked at the file and Medicare rules. The record shows that the Plan has approved 12 brushes for a six month period. The medical records do not include documentation of why an additional 288 brushes are necessary. Based on this information, we decided that Medicare rules for coverage of an additional 288 tracheostomy cleaning brushes have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 288 tracheostomy cleaning brushes (A4626).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on January 21, 2021.
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says screening tests are not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the lab services provided on January 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit (99205) to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that the member needs to have a follow up visit with you due to surgery in June 2020. The Plan denied your request. The Plan says there are in-network providers available for these 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 items/services at issue in this appeal. A routine post-surgery one year follow-up appointment is not considered emergent or urgent care. 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 an office visit (99205) to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous image-guided lumbar decompression (PILD).
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 the services are not covered.
The Plan must follow Medicare rules. The rules say that PILD will be covered by Medicare when provided in a clinical study under section 1862(a)(1)(E)of the Social Security Act (the Act) through Coverage with Evidence Development (CED). We looked at the file and Medicare rules. The file shows that the services are not being requested as part of a clinical study through CED. 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 percutaneous image-guided lumbar decompression (PILD).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views (73502) rendered by the out-of-network (OON) provider on April 22, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the radiologic examination, hip, unilateral, with pelvis when performed; 2-3 views (73502) rendered by the out-of-network (OON) provider on April 22, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health physical therapy services.

You asked the Plan to pre-approve home health services. You say that you need to keep your arm strong. The Plan denied your request. The Plan says you have no acute exacerbations or decline in your current level of function.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health services. Our physician reviewer found that in this case, the documentation does not support that you require additional skilled rehabilitation services to provide medically necessary treatment. You do not require skilled therapy services to improve your condition or perform a maintenance program to maintain your condition or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the requested home health services are not medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health physical therapy services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S1015, S8301) provided on March 2, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not payable.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. 

We looked at the file and Medicare rules. Codes S1015 and S8301 are assigned a status indicator of "I" under the Physician Fee Schedule, which means that these codes are not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (S1015, S8301) provided on March 2, 2021.
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 IRF services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
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 based on the records 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a subsequent nursing facility visit (99310) provided on February 20, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a subsequent nursing facility visit. You say that the services were provided with no adequate time frame to obtain authorization. You also say the services were medically necessary. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization. Th Plan also says there are in-network providers available for these 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 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. The records provided for review do not show that the services at issue were urgent or
emergent. 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 a subsequent nursing facility visit (99310) provided on February
20, 2021, by an out-of-network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics received from March 6, 2021, to March 21, 2021.

You asked the Plan to pay for foot orthotics. You say that this should be paid for. The Plan denied your request. The Plan says you chose to utilize a discount shoe store that is contracted and does not accept Medicare.

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 pay for foot orthotics received from March 6, 2021, to March 21, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomographic angiography (CTA) of the chest you had on February 8, 2021.
You asked the Plan to waive the copayment for the CTA of the chest. You say that you were hospitalized with the Coronavirus in November and this test was needed to see if the blood clot in your lungs had dissolved. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that diagnostic testing is not part of the Coronavirus treatment for which copayments are waived. The Plan also said that since the allowed amount for this test ($172.02) is less than your copayment obligation, you are responsible for the full allowed 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 $275 copayment per day for diagnostic radiology services.
You have been asked to pay a $275 copayment for the CTA of the chest. The CTA of the chest falls within the diagnostic radiology services benefit category. There is no provision in your contract for the waiver of this copayment. 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 computed tomographic angiography (CTA) of the chest you had on February 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on March 12, 2021.

You asked the Plan to waive the copayment for a specialist visit. You say that you were not charged for a previous visit and disagree with the 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 $30 copayment for specialist visits. 

You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the doctor 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 a specialist visit provided on March 12, 2021.