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

We decided that the Plan does not have to waive the copayment for the psychiatric evaluation provided on
December 16, 2020.

You asked the Plan to waive the copayment for the psychiatric evaluation. You say that this date of service was an information intake call. You say you are being overbilled because the provider went over the same information during your first visit. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for each covered therapy visit. 

You have been asked to pay a $40 copayment for the psychiatric evaluation. The psychiatric evaluation falls within the "Outpatient mental health care" benefit category. The medical record shows an intake visit was rendered. 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 psychiatric evaluation provided on December 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for specialist services provided by a participating provider on March 5, 2021.

You asked the Plan to waive the copayment for specialist services. You say that you do not understand why you are being billed for this. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $15 copayment for physician/practitioner services/specialist. 

You have been asked to pay a $15 copayment for specialist services. The correct copayment has been applied to the services that were provided. Specialist services fall within the physician/practitioner services/specialist 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 specialist services provided by a participating provider on March 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more than the benefit allowance for eyewear provided on February 24, 2021.

You asked the Plan to pay more than the benefit allowance for the eyewear. The Plan denied your request. The Plan says the claim was process with the correct $150 eyewear benefit allowance.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the Plan paid the eyewear allowance of $150. Therefore, we decided that the Plan does not have to pay more than the benefit allowance for eyewear provided on February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01830) provided June 13, 2020.
You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the records do not support the number of units billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code. 
We find that 74 units of CPT code 01830 are not supported in the medical record. The medical record only supports 64 units of CPT code 01830. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (01830) provided June 13, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aid, digital, binaural (V5258) provided April 3, 2020.
You asked the Plan to pay for the hearing aid. You say that your office checked the enrollee's benefits and was told there was a no maximum benefit for hearing aids. Nothing was mentioned that the enrollee could only use the Plan's vendor. The Plan denied your request. The Plan says the services are not covered when rendered by outside vendors.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered through the designated in-network vendor. The health plan contract specifically says that hearing aids ordered through providers other than the Plan's designated vendor is not covered. 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the hearing aid have not been met. Therefore, we decided that the Plan does not have to pay for hearing aid, digital, binaural (V5258) provided April 3, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aloxi for the enrollee.
You asked the Plan to pre-approve Aloxi. You say that this is medically necessary. The Plan denied your request. The Plan says that the drug is not being prescribed for a medically accepted indication.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 
We looked at the file and Medicare rules. Specifically, medical records were not provided for review in this case. The record shows that the Plan made multiple attempts to secure medical records, without success. Without medical records, we cannot determine if Medicare criteria are met in this case. Based on this information, we decided that Medicare rules for coverage of Aloxi have not been met. Therefore, we decided that the Plan does not have to pre-approve Aloxi for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87150, 87651, 87481, 87491, 87529, 87591, 87640, 87641, 87653, 87661, 87798, 87500, 877801, 87563, 87496) provided on July 30, 2020.

You asked the Plan to pay for laboratory services. You say that this should be covered at the in-network rate. The Plan denied your request. The Plan says this was not billed with the correct POS.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87150, 87651, 87481, 87491, 87529, 87591, 87640, 87641, 87653, 87661, 87798, 87500, 877801, 87563, 87496) provided on July 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group two power wheelchair and accessories.
You asked the Plan to pre-approve a group two power wheelchair and accessories. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested items.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 
The documentation provided does not show the enrollee utilizes intermittent catheterization for bladder management and progress notes do not describe evidence of severe leg edema. There is conflicting information in the documentation relating to the motorized wheelchair evaluation that states that the enrollee is able to safely transfer independently from the wheelchair to the bed but is unable to pressure relieve independently, there is no evidence of a history of a pressure ulcer. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group two power wheelchair and accessories.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency ambulance services (A0428), and ground mileage (A0425) provided on February 17, 2021.

You asked the Plan to waive the copayment for non-emergency ambulance services, and ground mileage. You say that you were not aware of the cost sharing responsibility. The Plan denied your request. The Plan says the copayment was 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 ambulance services. 

You have been asked to pay a $250 copayment for non-emergency ambulance services, and ground mileage. The services at issue 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 non-emergency ambulance services (A0428), and ground mileage (A0425) provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayments for the inpatient services and outpatient services provided from October 26, 2020, to November 5, 2020.

You asked the Plan to adjust the copayments for the inpatient and outpatient infusion services. You say that the copayment amounts are incorrect. The Plan denied your request. The Plan says you were charged the copayments 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 $345 copayment per day for inpatient hospital days 1-5 and a $295 copayment for each outpatient service.

You have been asked to pay a $345 copayment per day for 3 inpatient hospital days and a $213.73 copayment for 6 outpatient services for outpatient infusion services. The Medicare allowable for the infusion services is $213.73 which is why your copayment is less. 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 adjust the copayments for the inpatient services and outpatient services provided from October 26, 2020, to November 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on July 15, 2020 by an out of network (OON) provider.

You asked the Plan to pay for lab tests. You say that your facility is a reference laboratory and specimens are sent to you by physicians that are participating in the insurance accepted. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on July 15, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the Prolia injection provided on February 24, 2021.
You asked the Plan to waive the cost share for the injection services. You say that you were advised your copay would be $100 for the injection The Plan denied your request. The Plan says the claim processed 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 20% coinsurance for Medicare Part B prescription drugs. 
You have been asked to pay a 20% coinsurance for the injection services. The services fall 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 cost share for the Prolia injection provided on February 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa.

You asked the Plan to pre-approve Euflexxa. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 Euflexxa. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has osteoarthritis of the knee. The documentation does not support that the enrollee has trialed viscosupplemental treatments such as Orthovisc and Monovisc. The documentation does not outline contraindications or reasons these medications were not considered or that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the enrollee does not meet step therapy criteria for the requested drug.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: DME/ Orthotics
Decision: Unfavorable

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

We decided that the Plan does not have to pre-approve repeat Esophagogastroduodenoscopies (EGD).
You asked the Plan to pre-approve repeat Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) (43235) and Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239). You say that the enrollee continues with reflux, so you want to evaluate the esophageal ulcer. The Plan denied your request. The Plan says the prior endoscopy showed minimal inflammation and negative biopsies.
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 repeat Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) (43235) and Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239). Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the appellant meets none of the indications above and has responded well to medical management of the gastroesophageal reflux disease. Available records do not support the medical appropriateness nor necessity of a repeat EGD as proposed at this time. 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of repeat Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) (43235) and Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple (43239) have not been met. Therefore, we decided that the Plan does not have to pre-approve repeat Esophagogastroduodenoscopies (EGD).
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Entyvio, Injection, vedolizumab, 1 mg (J3380) every 6 weeks.

You asked the Plan to pre-approve Entyvio, Injection, vedolizumab, 1 mg (J3380) every 6 weeks. You say that the enrollee is experiencing increased symptoms so a higher Entyvio level is necessary. The Plan denied your request. The Plan says that Entyvio is approved for 300mg every 8 weeks for one year but the requested dosing regimen of every 6 weeks is not currently accepted best practice.

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 Entyvio, Injection, vedolizumab, 1 mg (J3380) every 6 weeks. Our reviewer says that the drug is medically reasonable and necessary. Our physician reviewer found appellant's available records as provided objectively evidence loss of Entyvio response to warrant a dose escalation as medically appropriate and necessary at this time. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio, Injection, vedolizumab, 1 mg (J3380) every 6 weeks have been met. Therefore, we decided that the Plan has to pre-approve Entyvio, Injection, vedolizumab, 1 mg (J3380) every 6 weeks.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lucentis 0.5MG/0.05.

You asked the Plan to pre-approve Lucentis. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 Lucentis. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has age-related exudative macular degeneration. The documentation does not support that the enrollee has tried and failed Avastin. 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. Therefore, the enrollee does not meet criteria for the requested drug. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have not been met. Therefore, we decided that the Plan does not have to pre-approve Lucentis 0.5MG/0.05.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient behavioral health services provided on October 13, 2020, to October 25, 2020 by an out of network (OON) provider.

You asked the Plan to pay for inpatient behavioral health services. You say that the state ordered the member to this hospital. The Plan denied your request. The Plan says prior authorization was 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 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 inpatient behavioral health services provided on October 13, 2020, to October 25, 2020 by an out of network (OON) provider.