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

We decided that the Plan does not have to waive the copayment for the office visit or waive the coinsurance for the botox injection provided on October 9, 2019.You asked the Plan to waive the copayment for the office visit and waive the coinsurance for the botox injection. The Plan denied your request. The Plan says that cost sharing is a contractual obligation and cannot be waived.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 $25 copayment for services obtained from a specialist and a 20% coinsurance foreach Medicare-covered Part B drug. You have been asked to pay a $25 copayment for the office visit and a 20% coinsurance for the botox injection. The office visit falls within the services obtained from a specialist benefit category and the botox injection falls within the Medicare-covered Part B drug 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 office visit and waive the coinsurance for the botox injection provided on October 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on September
9, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you do not want to pay the
copayment because the ambulance ride was not medically necessary. 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 $155
copayment for each one-way Medicare-covered ground trip.
You have been asked to pay a $155 copayment for the ambulance ride. The ambulance ride falls within the
each "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 ride provided on September 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SuperionVertiflex procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered by Medicare unless you are in a approved study.
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 procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found this spacer is experimental. More research is needed. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the SuperionVertiflex procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve sclerotherapy (varicose vein treatment) for the enrollee.
You asked the Plan to pre-approve the treatment. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare does not consider this treatment medically necessary if the skin on the areas to be treated with Varithena did not change.
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 treatment. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found within the last several months the enrollee has already undergone left iliac vein stenting, bilateral great saphenous vein radiofrequency ablation, sclerotherapy of the distal segments of the great saphenous veins bilaterally with these sclerotherapy sessions occurring on 3 separate days within 1 week. The area considered for additional sclerotherapy is an incompetent perforator measuring 2.9 mm with the reflux time of 0.5 seconds connecting to a great saphenous vein tributary. Additionally, the enrollee has a history of arthritis, peripheral vascular disease, former smoking, and pulmonary embolism. There is no documentation of an ulcer associated with this perforator. The reflux in this perforator vein is minimal. The documented reflux in the perforator vein is not greater than 0.5 seconds. The tributary vein overlying the perforator is not greater than 4.9 mm. Additionally, there is no documentation of ulceration overlying the perforator vein and therefore unable to overturn the health plan determination on the basis of medical necessity. 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 treatment have not been met. Therefore, we decided that the Plan does not have to pre-approve sclerotherapy (varicose vein treatment) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is not enough support for use in the treatment of liver cancer and kidney cancer.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the drug is not FDA-approved for use in unresectable hepatocellular carcinoma (HCC). The clinical study noted by the prescriber, the IMBrave 150 trial (NCT03434379) required the patients to have Child-Pugh A scores. Therefore the enrollee would not have been eligible for the trial. The trial does not reflect his clinical situation. The submitted documentation does not include a Child-Pugh score. Therefore, the documentation does not support that the drug would be medically reasonable and necessary nor that it would be safe and effective 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Tecentriq for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 22, 2018.
You asked the Plan to pay for office visit. You say that you are appealing with proof of timely filing. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not filed within the timely filing limit.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for office visit was not filed until December 8, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an office visit provided on October 22, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on November 15, 2019 through November 22, 2019.You asked the Plan to pay forthe home infusion therapy. You say that you would like reconsideration because per CMS, CPT code S9328 is valid for Medicare.The Plan denied your request. The Plan says CPT code S9328 has a status code if I and is not valid for Medicare purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule CPT code S9328 has a status code of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion therapy (S9328) provided on November 15, 2019 through November 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to enrollee on November 19, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that MolDX will reimburse approved tests.The test at issue was not approved through the MolDx program for the date of service at issue.Therefore, we decided that the Plan does not have to pay forthe laboratory services rendered to enrollee on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair glide.
You asked the Plan to pre-approve a stair glide. You say that the stair lift is medically necessary for you because you have arthritis and you cannot walk well. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says medical conditions are stable and do not require physician oversight.
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 enrollee is not medically stable after onset of atrial fibrillation and CHF. The enrollee can benefit from a continued stay in the acute hospital setting, rather than IRF. The enrollee may benefit from further PT and OT, but does not require an intensive therapy program. IRF admission is not medically appropriate based on her current functional status and medical instability. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on December 2, 2019.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services provided on December 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on November 22, 2019.
You asked the Plan to waive the copayment for the laboratory work. You say that you had a an office visit on the same day and had to pay an additional $20 copayment. You say you are appealing the $20 copayment as 'copayment stacking.' 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 $20 copayment for Medicare-covered laboratory tests. This copayment does not apply to blood draws or INR testing (anti-coagulant testing). You will only pay one copayment per day even if multiple lab tests are performed. You have been asked to pay a $20 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows that the laboratory work is considered a separate service.
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 laboratory work provided on November 22, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the enrollee has diabetes and on the date of service he had a diabetic seizure. You say that you called 911 to request assistance and when they arrived the evaluated the enrollee's blood sugar levels. Upon finding them extremely low, they treated him and administered glucose through anIV. You say that after the enrollee stabilized, you declined ambulance transportation since the emergency was over. You say that the Plan should provide coverage because the responder assistance was medically necessary.The Plan denied your request. ThePlan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 24, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a cystoscopy provided on November 14, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an outpatient surgery. You say that these services were medically necessary. The Plan denied your request. The Plan says no prior authorization was 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 has network providers available who can provide 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 a cystoscopy provided on November 14, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 1, 2019.
You asked the Plan to pay for the non-emergent ambulance services. You say that the service was medically
necessary. The Plan denied your request. The Plan says you did not request 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 requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for the ambulance services provided  on October 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, each additional intraoral x-ray, the periodontal scaling and root planing, fluoride varnish application, gingival irrigation and periodontal procedure provided on November 13, 2019.
You asked the Plan to pay more for the periodic oral evaluation, each additional intraoral x-ray, the periodontal scaling and root planing, fluoride varnish application, gingival irrigation and the periodontal procedure. You say that the provider was in-network. You say that you are appealing the copayment. The Plan denied your request. The Plan says the copayments for the periodic oral evaluation, each additional intraoral x-ray, and the periodontal scaling and root planing applied correctly. The Plan also says the fluoride varnish application, gingival irrigation and periodontal procedure are not covered benefits.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the fluoride varnish application, gingival irrigation and periodontal procedure are not among those covered under this benefit. The copayments for the periodic oral evaluation, each additional intraoral x-ray and periodontal scaling and root planing correctly applied. You have only been asked to pay $350 for the dental services provided, which is less than the total cost of $1,275.
Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, each additional intraoral x-ray, the periodontal scaling and root planing, fluoride varnish application, gingival irrigation and the periodontal procedure provided on November 13, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF)  services.You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says the enrollee has no skilled therapy or skilled nursing service needs.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.Continued SNF services beyond March 30, 2020 was requested. 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 continued services. Our physician reviewer found that from a nursing perspective, you have stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehab services, you are dependentwith bed mobility and transfers. You are non-ambulatory. There are no identifiable skilled therapy service needs. You do 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF)  services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient mental health services provided October 23 to October 24, 2019.You asked the Plan to pay for the inpatient mental health services. You say that the services were medically necessary.The Plan denied your request. The Plan says services after October 22, 2019 were not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the inpatient mental health services. Our reviewer says that services provided on and after October 23 were not medically necessary. Our physician reviewer found review of the records show that the enrollee does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of October 23, 2019 forward as this patient was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations. 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 inpatient mental health services have not been met.Therefore, we decided that the Plan does not have to pay for inpatient mental health services provided October 23 to October 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approveProlia. The Plan denied your request. The Plan says the enrollee is not high risk, and there is no history of fractures.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 physician reviewer found that based on a January 2019 bone density study, the enrollee has osteopenia, not osteoporosis. There is no evidence that previously used medications were ineffective or not tolerated. There is no documentation as to why standard medications to treat osteopenia/osteoporosis would not be expected to be effective for this enrollee. Therefore, the requested Prolia is not shown to be currently medically necessary or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approveProlia.