Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the contact lenses.

You asked the Plan to pay for the contact lenses. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the cost of your contact lenses was $408 and the $100 allowance was applied.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when a $100 credit toward your purchase of other contact lenses.

We looked at the file and the Plan's rules. You received the $100 allowance for the non-preferred brand of contact lenses. Based on this information, we decided that the Plan's rules for coverage of the contact lenses have been met. Therefore, we decided that the Plan does not have to pay for the contact lenses.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Methocarbamol for the enrollee.

You asked the Plan to pre-approve this drug. You say that these services are medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Methocarbamol for the enrollee.

Benefits for this drug 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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care.

You asked the Plan to waive the copayment for emergency care. You say that you were admitted to the hospital
and should not be responsible for 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 $110
copayment for emergency care.

You received emergency care. The record shows that you were admitted under observation, not inpatient. Please note that this is in your financial favor. Therefore, you are responsible to pay the $110 copayment. 

You have been asked to pay a $110 copayment for emergency care. Emergency care 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 emergency care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a diagnostic hearing exam.

You asked the Plan to waive the copayment for a diagnostic hearing exam. You say that you should not owe a copayment for the service. 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 $40 copayment for each diagnostic hearing exam to treat diseases and conditions of the ears for hearing services.

The medical records show that you received a diagnostic hearing exam. Therefore, you are responsible to pay the $40 copayment.

You have been asked to pay a $40 copayment for a diagnostic hearing exam. A diagnostic hearing exam 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 a diagnostic hearing exam.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Pegfilgrastim.

You asked the Plan to pre-approve Pegfilgrastim. The Plan denied your request. The Plan says that the enrollee does now have a fever, and the absolute neutrophil count is not available.

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 Pegfilgrastim. Our physician reviewer found that the enrollee, with metastatic pancreatic adenocarcinoma, will be treated with fluorouracil, folinic acid and Onivyde. There is documentation that the requested use of Pegfilgrastim is FDA-approved for the enrollee's diagnosis. Pegfilgrastim is used to decrease the risk of infectious complications (as manifested by febrile neutropenia) in patients with non-myeloid malignancies receiving myelosuppressive antineoplastic therapy that is associated with a clinically important risk of severe neutropenia with fever. The American Society of Clinical Oncology guidelines state that risk factors for febrile neutropenia include age greater than 65, advanced disease, liver disease and type of chemotherapy used among other factors. This enrollee is 78 years of age, has advanced metastatic disease, and the records indicate a history of alcoholic liver disease. Also the Medicare-approved major drug compendia report the following with regard to fluoruracil: "Leukopenia, predominantly of the granulocytopenic type, thrombocytopenia, and anemia occur commonly with fluorouracil therapy." The compendia also report the following of Onivyde therapy: "Conventional or liposomal irinotecan can induce severe myelosuppression, particularly neutropenia, Ref and deaths caused by sepsis have been reported in patients treated with the drug." The documentation does support that the requested drug is safe and effective and otherwise reasonable and necessary for this enrollee. Primary prophylaxis of febrile neutropenia with Pegfilgrastim is reasonable and necessary for this 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 Pegfilgrastim have been met. Therefore, we decided that the Plan has to pre-approve Pegfilgrastim.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial denture.

You asked the Plan to pre-approve a partial denture. You say that a partial denture is medically necessary. The Plan denied your request. The Plan says this benefit is not currently available as you received denture benefits.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, your denture benefit is not currently available as five years have not passed since the last covered denture. Therefore, we decided that the Plan does not have to pre-approve a partial denture.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis for the enrollee.

You asked the Plan to pre-approve this drug. You say that the enrollee needs to continue treatment with this drug. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Restasis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography and neuromonitoring provided to the enrollee.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says this claim was denied based on the associated diagnosis and could not be overturned due to a lack of clinical 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.

There is insufficient information provided to verify if the service should be paid for by the Plan. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography and neuromonitoring provided to the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).

You asked the Plan to pre-approve this service. You say that this service is medically necessary for the treatment of lumbar spinal stenosis. The Plan denied your request. The Plan says this service is 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 in denying the request to pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the device is experimental. More research is needed to show safety and efficacy.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drug.

You asked the Plan to pay for the self-administered drug. You say that you feel the self-administered drugs should be covered since it was part of your outpatient surgery. The Plan denied your request. The Plan says the drug that you received is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drug that you received is not covered under Medicare Part B.

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 pay for the self-administered drug.

Benefits for the self-administered drug 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis.

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 there is no valid proof of delivery.

The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery.

We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the shoulder elbow wrist hand orthosis.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rabeprazole for the enrollee.

You asked the Plan to pre-approve this drug. You say that the enrollee is doing well on this medication. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Rabeprazole for the enrollee.

Benefits for this drug 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure.

You asked the Plan to pay for the preventive procedure. You say that you were advised by the Plan that you could go to this treating facility and services would be covered. The Plan denied your request. The Plan says this service is not covered.

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 the preventive procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision services provided by a participating provider.

You asked the Plan to waive the copayment for vision services. You say that you thought this copayment would be waived. 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 $25 copayment for vision care/per visit.

You have been asked to pay a $25 copayment for vision services. The correct copayment has been applied to the services that were provided. Vision services fall within the vision care/per visit 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 vision services provided by a participating provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage.

You asked the Plan to pre-approve continued SNF coverage. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services exceed the enrollee's benefit limit.

The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.

The file shows that the enrollee received 100 days of SNF care during the benefit period. The Plan has covered 100 days of SNF care.

Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) coverage.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Udenyca.

You asked the Plan to pre-approve Udenyca. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that routine costs associated with a clinical trial are non-covered by the Plan. 

We looked at the file and Medicare rules. Review of the file shows that the enrollee is enrolled in a clinical trial. The requested drug is associated with the clinical trial. Based on this information, we decided that Medicare rules for coverage of Udenyca have not been met. Therefore, we decided that the Plan does not have to pre-approve Udenyca.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the intraoral-periapical radiographic image (D0230) and the
unspecified preventive procedure (D1999).

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says you have exhausted the allowable benefit for
coverage of the intraoral x-ray provided. Additionally, participating providers receive a monthly stipend for the
unspecified preventive procedure provided; therefore, additional payment cannot be issued for this service.

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.

We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of these services have not been met. Specifically, the Plan contract covers one intraoral x-ray per
calendar year. You received two intraoral x-rays on this date of service, in which the Plan issued payment for
one intraoral x-ray. You have exhausted the allowable benefit for this service. Additionally, payment cannot be
issued for the unspecified preventive procedure as participating providers receive a monthly stipend for this
service. Therefore, we decided that the Plan does not have to pay for the intraoral-periapical radiographic
image (D0230) and the unspecified preventive procedure (D1999).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the COVID testing.

You asked the Plan to pay for the COVID testing. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says that the services received are not a covered benefit.

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. Review of the file shows that the Plan states that this testing is not covered. The
Plan did not provide documentation including Medicare rules to support that these services are not covered.
The Plan did not substantiate their denial. Therefore, we decided that the Plan has to pay for the COVID testing.

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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued home health services.

You asked the Plan to pre-approve continued home health services. You say that you need continued physical therapy to be able to walk. The Plan denied your request. The Plan says you no longer need home health care.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued home health services. Our reviewer says that continued home health services are not medically necessary. Our physician reviewer found the documentation provided does not support that you require additional skilled rehabilitation services. You do not require additional services to improve your condition, perform a maintenance program, or prevent deterioration. You have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued home health services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued home health services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the hand cast application.

You asked the Plan to waive the copayment for the hand cast application. You say that you should not be responsible for this additional copayment because this was a part of the follow-up appointment and was needed. 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 $45 copayment for specialty physician.

You have been asked to pay a $45 copayment for the hand cast application. The hand cast application falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.

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 hand cast application.