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

We decided that the Plan does not have to waive the cost sharing for radiation therapy services you received from January 6. 2021, to February 16, 2021.

You asked the Plan to waive the cost sharing for the radiation therapy services and specialist visits. You say that you were never told there would be a copayment for treatment. The Plan denied your request. The Plan says you were charged this coinsurance correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for radiation therapy services and a $30 copayment for each specialist visit.

You have been asked to pay 20% coinsurance for the radiation therapy services and a $30 copayment for each specialist visit. 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 radiation therapy services and specialist visits you received from January 6. 2021, to February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical placement of an implant (D0610 x 2), the initial
15 minutes of deep sedation (D9222), and the additional 15 minutes of deep sedation (D9223 x 2) provided on
September 25, 2020.

You asked the Plan to pay for the dental services. You say that you are on social security. You say that you
needed these services. You also say that you will turn the plan into the insurance commissioner if there is no
result. The Plan denied your request. The Plan says implants are not listed as covered services. The Plan says
that anesthesia is not a covered service either. The Plan also says that you did not contact the Plan prior to the
date of service to verify benefits and provider eligibility.

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, implants are not among those covered
under this benefit. Additionally, although anesthesia is listed as a covered service, it is not covered when
performed in conjunction with non-covered services, such as implants Therefore, we decided that the Plan does
not have to pay for the surgical placement of an implant (D0610 x 2), the initial 15 minutes of deep sedation
(D9222), and the additional 15 minutes of deep sedation (D9223 x 2) provided on September 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a practitioner visit provided on September 18, 2020 by an out of network (OON) provider.

You asked the Plan to pay for practitioner visit. You say that this service was medically reasonable and necessary, and your provider was unaware that the nursing facility did not obtain authorization. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 a practitioner visit provided on September 18, 2020 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray services coded 73562 provided on March 19, 2021.

You asked the Plan to pay for the x-ray services. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says the services billed are not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 73562 for the x-ray services has a bundled relationship with code 73564 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray services coded 73562 provided on March 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IMFINZI (J9173).

You asked the Plan to pre-approve IMFINZI. You say that the drug is medically necessary. The Plan denied your request. The Plan says this drug is not medically necessary or reasonable.

The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 

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 IMFINZI. Our reviewer says that the drug is not medically necessary or reasonable. Our physician reviewer found per compendia, IMFINZI is approvable only after a response from chemotherapy/radiation for a stage II and III disease. The enrollee has a stage IV disease. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IMFINZI have not been met. Specifically, this drug is only approved for stage II and III diseases after a response from chemotherapy/radiation. This member is stage IV, and therefore, the drug is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve IMFINZI (J9173).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a paravertebral injection (64490) provided
on January 22, 2021.
You asked the Plan to waive the copayment for an injection. You say that you believe the copayment should be
waived as you were in the provider's office for fifteen minutes. The Plan denied your request. The Plan says the
copayment you are being charged is correct.
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 $100
copayment per day, for outpatient hospital services and procedures.
You have been asked to pay a $100 copayment for an injection. The EOC confirms $100 is the required
copayment per day for outpatient procedures. An injection falls within the outpatient hospital 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 a paravertebral injection (64490) provided on
January 22, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the comprehensive hearing test provided on February 5, 2021.
You asked the Plan to waive the copayment for the comprehensive hearing test. You say that your physician told you the test would be $0 because it is part of 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 $25 copayment for Hearing Services. You have been asked to pay a $25 copayment for the comprehensive hearing test. the comprehensive hearing test falls within the Hearing 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 comprehensive hearing test provided on February 5, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from January 30, 2021, to February 28, 2021.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.

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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from January 30, 2021, to February 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hip x-ray rendered on September 2, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the claim has not been processed by the primary insurance.

The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.

The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has confirmed that the primary insurance was effective as of January 1, 2015. The Plan has not received an Explanation of Benefits (EOB) from the primary insurance for this claim. As the secondary insurer, the Plan cannot be held responsible for these services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the hip x-ray rendered on September 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for treatment with Omidria (J1097) provided
during cataract removal surgery on February 17, 2021.
You asked the Plan to waive the coinsurance for Omidria. You say that you thought the administration of
Omidria was all part of the cataract surgery services. The Plan denied your request. The Plan says the correct
coinsurance was 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 20%
coinsurance for each Medicare-covered Part B drug obtained in a provider's office or outpatient setting.
You have been asked to pay $81.37, or 20% of the Medicare-allowed charge of $406.84, for Omidria. Omidria
falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the
coinsurance for treatment with Omidria (J1097) provided during cataract removal surgery on February 17,
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 1-surface filling (D2391), the 2-surface fillings (D2331 x
3), the core build up (D2950 x 2), the crowns (D2740 x 2), and the root canal (D3310) provided from
September 29, 2020, to March 2, 2021.

You asked the Plan to pay for the dental services. You say that the chemotherapy that you received caused you
to have dry mouth. You say that this is when you began to have issues with your teeth. You say that you feel
these services should be covered under your medical insurance as they are a side effect of treatment for a
medical condition. The Plan denied your request. The Plan says the services that you received are routine in
nature. The Plan says that routine dental services are not covered by Medicare. The Plan says there is a
maximum benefit of $1,000 for covered routine dental services each year for 2020 and 2021. The Plan also
says that the maximum benefit has been exhausted for both years.

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.

The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Though the Plan offers a dental benefit in excess of Medicare coverage, the maximum benefit
for 2020 and 2021 have been exhausted. The record shows that the Plan paid $1,000 for dental services
performed on September 29, 2020, and $1,000 for services performed on February 2, 2021, which exhausted
the benefits. Therefore, we decided that the Plan does not have to pay for the 1-surface filling (D2391), the 2-
surface fillings (D2331 x 3), the core build up (D2950 x 2), the crowns (D2740 x 2), and the root canal
(D3310) provided from September 29, 2020, to March 2, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.
You asked the Plan to pre-approve Gelsyn-3. 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.
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 Gelsyn-3. Our reviewer says that the
medication is not medically necessary. Our physician reviewer found based on the medical records provided
the enrollee has not tried and failed the required drug(s). There is no indication that the plan's required drug(s)
would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have
to pre-approve Gelsyn-3.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a SNF admission.

You asked the Plan to pre-approve the SNF admission. You say that you need time in a SNF to make sure you are able to be on your own. The Plan denied your request. The Plan says you have no daily skilled therapy or skilled nursing needs.

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 admission. Our reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting.

We looked at this physician's review, the file, and Medicare rules. Although you have skilled therapy needs, these needs are not on a daily basis. Based on this information, we decided that Medicare rules for coverage of the SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve a SNF admission.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an intraoral complete series of radiographic images (D0210).
You asked the Plan to pay for an intraoral complete series of radiographic images. You say that you were told
by your provider that all the services were covered. The Plan denied your request. The Plan says the service at
issue is not a covered benefit.
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 requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an
intraoral complete series of radiographic images (D0210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the mandibular partial denture (D5214) provided on January 28, 2021.

You asked the Plan to pay more for the mandibular partial denture. You say that this service was medically necessary, and you believe it should be covered. The Plan denied your request. The Plan says the calendar year maximum has been reached.

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 Plan offers a $2,000 combined allowance for supplemental preventive and comprehensive dental services every year. The contract says that you are responsible for any amount over and above the allowance amount. The record shows that you met the annual maximum benefit while processing this claim for the January 28, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay more for the mandibular partial denture (D5214) provided on January 28, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the genetic testing services provided on January 13, 2021.

You asked the Plan to waive the cost share for the services provided. You say that you were not aware of the cost of the procedure. The Plan denied your request. The Plan says you are responsible for the cost share.

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 genetic testing. 

You have been asked to pay a 20% coinsurance for the services provided. The services fall within the outpatient diagnostic tests 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 genetic testing services provided on January 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for physical therapy (PT) services provided from August 12, 2020, to September 12, 2020.

You asked the Plan to waive the copayments for the PT services. You say that you should have a copayment of $10 per visit, not $40. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that a $10 copayment per visit only applies if you receive the OT services at a specialist's office or a comprehensive outpatient rehabilitation facility. The facility where you received these services is an outpatient hospital facility.

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 per visit for outpatient rehabilitation services in an outpatient hospital facility.

You have been asked to pay a $40 copayment per visit for the PT services. The PT services fall within the outpatient rehabilitation services in an outpatient hospital facility 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 copayments for physical therapy (PT) services provided from August 12, 2020, to September 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on February 10, 2021.

You asked the Plan to pay for an office visit. You say that this should be covered. The Plan denied your request. The Plan says this is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 99214 has a bundled relationship with code 31575 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99214) provided on February 10, 2021.