Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe services provided to the enrollee from January 13, 2020 through January 27, 2020 provided by an in-network provider.You asked the Plan to waive the copayment forthe services. You say that you are appealing the member's cost-share responsibility for the services the member received.The Plan denied your request. The Plan says the claim was processed accordingly with the member's 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 shows that the enrollee was admitted for in-network inpatient hospital care on January 13, 2020 and discharged on January 15, 2020. The enrollee was asked to pay a $295 copayment per day from January 13, 2020 through January 14, 2020, days 1-2 of their inpatient hospital care. Per the enrollee's contract there is a $295copayment per day required for days 1-7. The enrollee was transferred for inpatient mental health services on January 15, 2020 and discharged on January 27, 2020. The enrollee was asked to pay a $1,763 copayment for the in-network inpatient mental health care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan doesnot have to waive the copayment forthe services provided to the enrollee from January 13, 2020 through January 27, 2020 provided by an in-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the urinary tract infection panel provided on February 3, 2020.
You asked the Plan to pre-approve the provided testing. You say that the services were required to treat the enrollee safely and accurately. The Plan denied your request. The Plan says molecular genetic screening testing is not a Medicare benefit for the diagnoses listed.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. In this case, there were insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee at the time of service. This testing is not covered for screening purposes. Therefore, we decided that the Plan does not have to pre-approve the urinary tract infection panel provided on February 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography provided on December 31, 2019.You asked the Plan to waive the copayment for the echocardiography. You say that you were billed twice for the same procedure. You say that you should only owe one 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 $65 copayment for each covered diagnostic procedure or test at a network doctor's office. You have been asked to pay a $65 copayment for the echocardiography. The echocardiography falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the provider interpreted the test. 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 echocardiography provided on December 31, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humira.
You asked the Plan to pre-approve Humira. You say that the enrollee has shown improvement and is doing very well on Humira. The Plan denied your request. The Plan says the requested drug is not covered under the enrollee's medical plan.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Humira.
Benefits for Humira may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveShingrix injection.You asked the Plan to pre-approveimmunization. You say that this vaccine is used for the prevention of herpes zoster (shingles).The Plan denied your request. The Plan says the denial of authorization for this immunization is correct, because this immunization is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D benefits.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to immunization.Therefore, we decided that the Plan does not have to pre-approveShingrix injection.Benefits for immunizationmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 26, 2019 through March 1, 2019.You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met.Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from February 26, 2019 through March 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecervical facet joint blocks.You asked the Plan to pre-approvethe requested services. The Plandenied your request. The Plan says documentation does not show that the enrollee's pain was reduced by at least 50% after the last injection.The Plan follows Medicare rules. Medicare rules say that facet joint blocks are only covered under certain medical indications.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 requested services. Our physician reviewer found that the enrollee has severe left C1-2 facet degenerative joint disease with upper left sided cervical pain. He also has severe bilateral C3-4 facet arthritis, severe left C1-2 facet arthritis, Severe right C7-T1 facet arthritis, severe right and moderate to severe left C2-3 facet arthritis, severe right and moderate left C4-5 facet arthritis, moderate to severe C5-6 spondylosis, small C6-7 vacuum disk, severe bilateral C3-4 C4-5 and C5-6 foraminal stenosis, severe right C6-7 foraminal stenosis, moderate bilateral C2-3 foraminal stenosis, mild to moderate C5-6 cord compression, and left sided neck pain.  Pain is a 7-8 out of 10, which started 3 months ago. Pain is dull, intermittent, wakes him at night. It is worse with athletic activity, turning head to left andimproves with lying down. Conservative therapy of physical therapy, anti-inflammatories and steroids should be completed before interventional therapy. Further, any injection of the C1-C2 joint is considered experimental/ investigational. The documentation from prior blocks is not clear that sustained 50% pain relief was achieved. Therefore, the request is considered as not medically reasonable and necessary 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approvecervical facet joint blocks.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve continued dermatology care from an out of network (OON) tertiary level provider.

You asked the Plan to pre-approve the OON tertiary dermatology care. You say that you have been working with this provider and have been able to manage your condition with these services. You feel you should be allowed to continue this. The Plan denied your request. The Plan says that the enrollee is receiving off-label treatment and can be managed at non-tertiary provider from the plan's network.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. The rules say that Plans must arrange care with out of network providers when necessary care is not available within the network. 

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 OON tertiary dermatology care. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is receiving ongoing off-label treatment for alopecia areata with a JAK inhibitor which has been successful. Continued care at a tertiary-level academic institution is reasonable and necessary and a non-tertiary level provider would not be able to manage this treatment. 

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 OON tertiary dermatology care have been met. Therefore, we decided that the Plan has to pre-approve continued dermatology care from an out of network (OON) tertiary level provider.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the pseudoaneurysm injection provided on January 30, 2020.
You asked the Plan to waive the copayment for the pseudoaneurysm injection. You say that you still don't know if the issue is resolved or if you need another procedure. You say that you shouldn't have to pay additional copayments. 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 $325 copayment for surgical services at an in-network outpatient hospital facility. You have been asked to pay a $325 copayment for the pseudoaneurysm injection. The pseudoaneurysm injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 pseudoaneurysm injection provided on January 30, 2020.
Your complaint about the hospital and doctor error is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve vascular visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve vascular visits. You say that you would like these services approved. 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. 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 vascular visits to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 10, 2020.
You asked the Plan to pay for the physician's 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 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 physician's services provided on January 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.Welooked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong-term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveproton beam therapy.You asked the Plan to pre-approveproton beam therapy. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not 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 indenying the request to pre-approve proton beam therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has prostate cancer. The theoretical advantage of proton beam therapy is in its dose distribution. Proton beam therapy thus permits the delivery of high doses of RT to the target volume while limiting the "scatter" dose received by surrounding tissues. Use of proton beam RT is expanding as more proton beam treatment centers open. However, there are no randomized trials comparing proton beam therapy with photon therapy or brachytherapy in men with clinically localized prostate cancer. A systematic review of the available evidence from ASTRO on efficacy and toxicity concluded that outcomes were similar with proton beam therapy and intensity-modulated radiation therapy (IMRT) using photons but did not demonstrate a benefit for the proton beam approach. Clinical practice guidelines form the American Urological Association (AUA)/American Society for Radiation Oncology (ASTRO)/Society of Urologic Oncology (SUO)/American Society of Clinical Oncology (ASCO) conclude that proton beam therapy offers no clinical advantage over other forms of definitive treatment. Therefore, the enrollee does not meet criteria for the requested services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveproton beam therapy.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Breath Activated Call Light.
You asked the Plan to pre-approve a Breath Activated Call Light (A9280). You say that you need a Breath Activated Call Light. The Plan denied your request. The Plan says a Breath Activated Call Light is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. Records show that a Breath Activated Call Light (A9280) is being requested for use in a SNF. Also, a life alert system is an emergency communications system which does not serve a diagnostic or therapeutic purpose and is excluded from coverage by Medicare. Therefore, we decided that the Plan does not have to pre-approve a Breath Activated Call Light.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay fororthopedic surgery provided in Mexico from November 18, 2019 to December 5, 2019. You asked the Plan to pay fororthopedic surgery. You say that you needed to seek services elsewhere because your primary care physician did not address your condition.The Plan denied your request. The Plan says these services were not emergency services.Medicare rules say that items and services furnished outside the United States are generally excluded from coverage. The Plan offers additional coverage for emergent services provided outside of the United States.We looked at the file and Medicare rules. The records show that the services at issue were not emergent or due to unforeseen circumstances. Based on this information, we decided that Medicare rules for coverage of orthopedic surgery have not been met.Therefore, we decided that the Plan does not have to pay fororthopedic surgery provided in Mexico from November 18, 2019 to December 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 18, 2019 by an out of network (OON) provider.You asked the Plan to pay for skilled nursing services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the member's primary care physician did not refer these services. The Plan says that 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 skilled nursing services provided on November 18, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair (E0240).
You asked the Plan to pre-approve a shower chair. You say that a shower chair is medically necessary. The Plan denied your request. The Plan says a shower chair is not a covered benefit under your contractual policy.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate for you 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 shower chair (E0240).