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

We decided that the Plan does not have to pre-approve office visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve OON office visits. You say that this provider is easier for you to get to. The Plan denied your request. The Plan says the requested services are available in-network.
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 office visits to be provided by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ECG provided on December 12, 2019.
You asked the Plan to waive the copayment for an ECG. You say that you disagree with the charges because this was part of your annual wellness visit. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for diagnostic procedures and tests. You received an ECG on December 12, 2019. ECG's are not included in annual wellness visits. Therefore, you are responsible to pay the $50 copayment. You have been asked to pay a $50 copayment for an ECG. An ECG falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an ECG provided on December 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Horizant
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
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 Horizant
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl DIS 12mcg/hr 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 this medication falls under Part D coverage.
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 Fentanyl DIS 12mcg/hr for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee does not need daily doctor visits, or have multiple medical conditions that need complex medical management.
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 rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for a dislodged feeding tube, which has since been replaced. Additionally, the enrollee had a fever and was ruled out for CoViD-19. The enrollee has a tracheotomy and is ventilator dependent at baseline. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda for the enrollee.
You asked the Plan to pre-approve Keytruda. The Plan denied your request. The Plan says that the enrollee does not meet criteria for Keytruda.
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 Keytruda. Our reviewer says that Keytruda is not medically reasonable and necessary for the enrollee in this case. For urothlial cancer pembrolizumab is FDA approved for the treatment of locally advanced or metastatic urothelial cancer in patients who are not eligible for cisplatin-containing chemotherapy and whose tumors express PD-L1 (CPS &#8805;10) as determined by an approved test, or in patients who are not eligible for any platinum-containing chemotherapy regardless of PD-L1 status or the treatment of locally advanced or metastatic urothelial cancer in patients with disease progression during or after platinum-containing chemotherapy or within 12 months of neoadjuvant or adjuvant platinum-containing chemotherapy. This patient has not received any platinum containing regimens and has no clear contraindications. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Keytruda. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have not been met. Therefore, we decided that the Plan does not have to pre-approve Keytruda for the enrollee.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient care provided from August 3, 2019 to August 16, 2019.
You asked the Plan to pay for inpatient care. You say that these services were partially approved and medically necessary. The Plan denied your request. The Plan says that these services were not authorized.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 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 inpatient care. Our reviewer says that the criteria for coverage of these services have been met. Our physician reviewer found the enrollee presented in septic shock and required intensive care unit (ICU) level of care services and multi-specialty evaluations. He was transferred to the medical floor and then required transfer to the ICU. He was hospitalized until considered medically stable for discharge on August 16, 2019. The review has determined that the treating physician did document that the patient was not stable for transfer on any dates of service. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient care have been met. Therefore, we decided that the Plan has to pay for inpatient care provided from August 3, 2019 to August 16, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete mandibular denture.
You asked the Plan to pre-approve the services. You say that your dentures are too big and very uncomfortable, making it very difficult to eat. The Plan denied your request. The Plan says this is a benefit once every five 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 Plan covers dentures once every five years. The records show that you last received dentures in April 2019. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve a complete mandibular denture.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forskilled nursing services provided on October 28, 2019 by an out of network (OON) provider.You asked the Plan to pay forskilled nursing services. You say that it is the facility's responsibility to obtained prior authorization.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.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 forskilled nursing services provided on October 28, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 2, 2019 through October 18, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 show that you received inpatient hospital care from October 2, 2019 through October 18, 2019. Your EOC clearly states, enrollees must pay a $180 copayment each day for days 1-7 of a covered inpatient stay during a benefit period. 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 inpatient hospital care from October 2, 2019 through October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided by on November 18, 2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that you are appealing the charge for the colonoscopy. 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 $50 copayment for each covered specialist office visit. You have been asked to pay a $50 copayment for the colonoscopy. The colonoscopy falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The record shows the colonoscopy was provided in a specialist provider's office.
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 colonoscopy provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services coded 64445 provided on August 1, 2019.
You asked the Plan to pay for the injection services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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, the CPT Code Manual definition of code 64445 is injection(s), anesthetic agent(s) and/or steroid; sciatic nerve. We find that CPT code 64445 is not supported in the medical record. Specifically, the documentation submitted did not include documentation that a second injection was given. Therefore, the service and units billed cannot be verified. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the injection services coded 64445 provided on August 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve YERVOY.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of adrenal cancer with progressionto liver metastases. YERVOY is not FDA-approved for the treatment of adrenal cancer. Use for this diagnosis is also not supported by major drug compendia. The YERVOY is not reasonable or medically necessary 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveYERVOY.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan has to pay for an anesthetic agent, nerve block provided on May 23, 2019, May 28, 2019 and May 30, 2019.
You asked the Plan to pay for the anesthetic agent, nerve block. You say that you were informed by the provider that these services were medically necessary and you were not aware prior authorization was required. The Plan denied your request. The Plan says that there is no authorization on file.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not responded to our request to identify the name and network status of the referring provider to determine if these services were provided due to plan directed care. Therefore, we decided that the Plan has to pay for an anesthetic agent, nerve block provided on May 23, 2019, May 28, 2019 and May 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 15, 2019 by an out of network (OON) provider.You asked the Plan to pay forevaluation visit. You say that the facility requested your provider to treat the enrollee, therefore medical necessity is pre-established.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 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 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 forthe medical services provided on December 15, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from June 28, 2019 through July 17, 2019 by a non-participating provider.
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says the provider who performed these services is not within the network.
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 provider does not participate with your Plan and your EOC states, you must visit a participating dental network provider to receive dental benefits. A list of codes for services covered under this plan is included in the annual member package mailed to you before January 1st each year. Therefore, we decided that the Plan does not have to pay for the dental services provided from June 28, 2019 through July 17, 2019 by a non-participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for retainer crown - porcelain fused to high noble metal (D6750) provided on April 11, 2018.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the denied charges. The Plan denied your request. The Plan says you exhausted your maximum benefit allowance.
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. With the payment of claim 20180420001494 which totaled $5250.00 you exceeded your calendar year maximum of $3250.00 by $307.26 which is your responsibility. Each explanation of benefits has the plans calendar year maximum printed at the bottom along with how much you have used to date. Therefore, we decided that the Plan does not have to pay for retainer crown - porcelain fused to high noble metal (D6750) provided on April 11, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for negative pressure wound therapy electrical pump, stationary or portable (E2402) provided from October 30, 2019 through December 24, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 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 show that you received a negative pressure wound therapy electrical pump, stationary or portable (E2402) provided from October 30, 2019 through December 24, 2019. You are asked to pay 20% coinsurance for the DME. 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 negative pressure wound therapy electrical pump, stationary or portable (E2402) provided from October 30, 2019 through December 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to adjust the cost share for the podiatry services and walking boot
You asked the Plan to adjust the cost share for the podiatry services and walking boot. You say that you thought this podiatrist was in-network. The Plan denied your request. The Plan says you have been charged the cost share 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 $70 copayment for out-of-network podiatry services and a 40% coinsurance for out-of-network orthotic devices. You have been asked to pay a $70 copayment for out-of-network podiatry services and a 40% coinsurance for out-of-network orthotic devices for podiatry services and walking boot. 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 cost share for the podiatry services and walking boot
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ER visit provided on October 25, 2019.
You asked the Plan to waive the copayment for an ER visit. You say that you disagree with the charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $120 copayment for emergency care. You have been asked to pay a $120 copayment for an ER visit. An ER visit falls within the emergency care 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 an ER visit provided on October 25, 2019.