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

We decided that the Plan has to pre-approve Alimta.
You asked the Plan to pre-approve the Alimta. You say that the drug being requested is medically necessary. The Plan denied your request. The Plan says that the criteria for coverage have not been met. The Plan says that the use of this drug in this case requires that the enrollee has not progressed while on a previous regimen containing pemetrexed.
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 the Alimta. Our reviewer says that the documentation supports that the requested drug is safe, effective, and appropriate for this enrollee. Our physician reviewer found Alimta is FDA-approved for the enrollee's diagnosis. The requested drug is medically reasonable and necessary. 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 Alimta have been met. Therefore, we decided that the Plan has to pre-approve Alimta.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown and core buildup, including any pins when required provided on November 20, 2019.You asked the Plan to pay for the crown and core buildup. You say that you spoke with several Plan representatives who all advised you that this provider was in network and you did have dental coverage.The Plan denied your request. The Plan says these services are not covered benefits under your dental plan.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 crown and core buildup, including any pins when required provided on November 20, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on March 18, 2020.You asked the Plan to waive the copayment forthe emergency room visit. You say that you went to the emergency room under the assumption it would be for a PR/INR blood test and not additional services. You say you would like the copayment to be waived. 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. The medical record shows you received additional services during your emergency 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 copayment forthe emergency room visit provided on March 18, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on December 10, 2019.You asked the Plan to pay forthe laboratory services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services are not covered.The Plan must followMedicare rules. Medicare rules say that a physician order is not required to be signed, however, the physician must clearly document, in the medical record, his or her intent that the test be performed.We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the medical record. We find that the issue of intent is not clear. There are no medical records in the case file in regards to the physician's intent that the test be performed prior to services taking place.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on December 10, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2), and crown (D2740). You asked the Plan to pre-approve the core buildups and crown. You say that the two crowns are needed in order for the dentures to fit properly. You also say that it is medically necessary that these services be provided. The Plan denied your request. The Plan says core buildup is not a covered benefit under your plan. The Plan also says that your plan only allows one crown per year, and you were already approved for one crown per your plan 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, core buildup is not among those covered under this benefit. The contract also says that crowns are limited to one procedure per year. The record shows that you were approved for one crown on April 3, 2020 and your crowns benefit has been exhausted. Therefore, we decided that the Plan does not have to pre-approve two core buildups, including any pins when required (D2950 x2), and crown (D2740).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Zio patch cardiac monitor.
You asked the Plan to pre-approve a Zio patch cardiac monitor. You say that this is medically necessary. The Plan denied your request. The Plan says that there is no diagnosis or symptoms reported to meet criteria.
The Plan follows Medicare rules. Medicare rules say that electrocardiographic monitoring is only covered for 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 a Zio patch cardiac monitor. Our reviewer says that that a Zio patch cardiac monitor is not medically reasonable and necessary in this case. You had collapse greater than 6 months ago thought to be due to seizure activity with no sustained dysrhythmias on 48-hr Holter at that time, no recurrent collapse and no documented symptoms of palpitations, presyncope or syncope. In this circumstance the documentation provided does not support the medical necessity for a Zio Patch. Coverage criteria are not met since there are no documented covered symptoms required for the procedure. Our physician reviewer found that your condition does not meet Medicare criteria for a Zio patch cardiac monitor. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Zio patch cardiac monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Zio patch cardiac monitor.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the SNF stay provided from January 1, 2020 to January 12, 2020. You asked the Plan to waive the copayment for the SNF stay. You say that you were not advised that you would have a copayment per day while at the SNF. 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 $20 copayment. per day for days 1-20 of a benefit period and a $140 copayment per day for days 21-44 of a benefit period and a $0 copayment per day for days 45-100 of a benefit period. You have been asked to pay a $500 copayment for the SNF stay, which is less than the standard copayment. The SNF stay falls within the "Skilled nursing facility (SNF) 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 the SNF stay provided from January 1, 2020 to January 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewings, prophylaxis, and first intraoral periapical x-ray provided on February 6, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, bitewings, prophylaxis, and first intraoral periapical x-ray. You say that the Plan's guide says there is $0 copayment for cleanings, whether in or out of network. You also say that it does not show any maximum for this. The Plan denied your request. The Plan says first intraoral periapical x-ray is not a covered benefit. The Plan also says that the charges for the comprehensive oral evaluation, bitewings, and prophylaxis exceed the allowable amounts.
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, first intraoral periapical x-ray is not among those covered under this benefit. The Plan contract also clearly states that you may still be responsible for the difference between the billed amount and allowed amount for services received by an OON provider. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation, bitewings, prophylaxis, and first intraoral periapical x-ray provided on February 6, 2020 by an OON provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient rehabilitation stay provided from October 23, 2019 to November 12, 2019.
You asked the Plan to waive the copayment for the inpatient rehabilitation stay. You say that you should not be responsible for this copayment because you had already paid for the first hospital stay. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $300 copayment per day for days 1-5 for Medicare-covered in-network inpatient hospital stays. The enrollee has been asked to pay a $300 copayment for days 1 to 5 of the inpatient rehabilitation stay. ($300 x 5 = $1,500). The inpatient rehabilitation stay falls within the "Inpatient hospital care" benefit category. 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 does not have to waive the copayment for the inpatient rehabilitation stay provided from October 23, 2019 to November 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an additional 30 minutes of advance care planning (99498) provided on September 30, 2019.
You asked the Plan to pay for the additional 30 minutes of advance care planning.. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the billed service.
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 99498 is advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure). We find that CPT code 99498 is not supported in the record. Specifically, the record does not indicate that an additional 30 minutes of advance care planning services were rendered in addition to the initial 30 minutes. Based on this information, we decided that Medicare rules for coverage of the additional 30 minutes of advance care planning. have not been met. Therefore, we decided that the Plan does not have to pay for an additional 30 minutes of advance care planning (99498) provided on September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Face-down Recovery System.You asked the Plan to pre-approve a Face-down Recovery System. You say that your doctor told you that when surgery is done a face-down positioning device is necessary to avoid surgery again or loss of eyesight. The Plan denied your request. The Plan says Medicare does not cover face-down positioning devices for any reason. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is precautionary. Neither Medicare nor the Plan covers face-down positioning devices. Therefore, we decided that the Plan does not have to pre-approve a Face-down Recovery System.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on February 17, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe outpatient visit (99203). You say that you were unaware that you needed to apply with the Plan to be in-network providers.The Plan denied your request. The Plan says this provider is out-of-network and the services were not pre-authorized.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 whocan 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 February 17, 2020 by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a transthoracic echocardiography (TTE) test provided on January 16, 2020.
You asked the Plan to waive the copayment for TTE test. You say that this was a testing facility attached to a doctor's office, but not in or near a hospital. The Plan denied your request. The Plan says the copayment amount 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 $150 copayment for TTE test in an outpatient hospital facility. The rendering provider was an outpatient hospital facility; therefore, the outpatient hospital copayment applies to this claim. You have been asked to pay $150 copayment for TTE test. TTE test 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 a transthoracic echocardiography (TTE) test provided on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on March 17, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee
must receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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 that you provided on March 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 6, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the enrollee
-must receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the
physician's service 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 September 6, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from inpatient rehabilitation. The Plan denied your request. The Plan says the enrollee could be treated at an alternate level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's current medical status does not require intensive physician or nursing oversight in an IRF. The patient may benefit from additional multiple therapies, however the patient's functional level does not require or indicate that this therapy must be in an IRF with an intensive level program. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued use of the home ventilator, any type, used with non-invasive interface.
You asked the Plan to pre-approve continued use of the home ventilator (E0466). You say that the enrollee needs to continue to use the home ventilator The Plan denied your request. The Plan says the records submitted did not support the medical necessity required to approve the home ventilator.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. We looked at the file and Medicare rules. There is no compliance report in the case file. Based on this information, we decided that Medicare rules for coverage of continued use of the home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve continued use of the home ventilator, any type, used with non-invasive interface.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services rendered to the enrollee during an inpatient stay on
October 17, 2019.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says this claim cannot be paid separately based on Medicare guidelines for inpatient services.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other
than the facility or hospital for services or equipment furnished to a beneficiary. The facility or hospital must
furnish all necessary covered services to the beneficiary either directly or under arrangements made with
outside providers. This equipment and service was used during a facility inpatient stay. This equipment did not
go home with the enrollee. Payment for this service would have been included under the facility claim.
Payment to you for this service is the responsibility of the facility or hospital. Therefore, we decided that the
Plan does not have to pay for services rendered to the enrollee during an inpatient stay on October 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the mammogram provided on March 19,
2020.
You asked the Plan to waive the deductible for the mammogram. You say that this was your routine
mammogram and both claims should have been billed as a preventive service. 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. Your
contract with the Plan says that there is a $750 deductible that applies towards each basic imaging services
(e.g., x-rays or ultrasound).
The mammogram you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests
and therapeutic services and supplies" benefit category. The medical record shows a diagnosis of an abnormal
mammogram of left breast which makes the mammogram diagnostic in nature.
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that
applies towards each basic imaging services (e.g., x-rays or ultrasound). This cost sharing is a contractual
obligation that had not been met at the time the mammogram was received on March 19, 2020. Therefore, we
decided that the Plan does not have to waive the deductible for the mammogram provided on March 19, 2020.