Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the ambulance transport provided on September 25, 2020.
You asked the Plan to waive the deductible for the ambulance transport. You say that you could not have driven yourself to the hospital so you had no other choice but to use the ambulance. The Plan denied your request. The Plan says the deductible applied correctly.
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 your deductible is $400. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. The item or service you asked the Plan to waive the deductible for falls within the Ambulance services" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $400 deductible applies to ambulance services. This cost sharing is a contractual obligation that had not been met at the time the ambulance transport was received on September 25, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the ambulance transport provided on September 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Injectafer (J1439).
You asked the Plan to pre-approve Injectafer. The Plan denied your request. The Plan says the use of this drug in the enrollee's case requires the enrollee to have low iron (ferritin less than 100 ng/mL or transferrin saturation less than 20%). The Plan also says that the documentation does not support that the enrollee has low iron.
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 Injectafer. Our reviewer says that Injectafer is not medically reasonable and necessary for the enrollee. Our physician reviewer found the use of Injectafer (J1439) in this case requires the enrollee have low iron (ferritin less than 100 ng/mL or transferrin saturation less than 20%). The documentation indicates that the enrollee has normal iron stores and normal iron levels. Our reviewer found that the documentation does not support that the enrollee has low iron (ferritin less than 100 ng/mL or transferrin saturation less than 20%). The documentation does not support that the Injectafer (J1439) is medically reasonable and necessary for the enrollee. Our physician reviewer also found that the documentation does not support that the Injectafer (J1439) is safe and effective for the enrollee. The enrollee does not have low iron (ferritin less than 100 ng/mL or transferrin saturation less than 20%). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer (J1439).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).

You asked the Plan to pre-approve a pneumatic compression device. You say that the enrollee requires the device. The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.

The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (E0652).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the spinal puncture provided on May 10, 2018.
You asked the Plan to waive the deductible for the spinal puncture. You say that you do not want to pay for that. The Plan denied your request. The Plan says the deductible applied correctly.
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 your deductible is $1,000 out-of-network. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services. The item or service you asked the Plan to waive the deductible for falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $1,000 out-of-network deductible applies to outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time the spinal puncture was received on May 10, 2018. Therefore, we decided that the Plan does not have to waive the deductible for the spinal puncture provided on May 10, 2018.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.

You asked the Plan to pre-approve Botox. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. 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 Botox. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation indicates that you have a diagnosis of myofascial pelvic floor dysfunction, with vulvodynia, and atrophic vaginitis. These diagnoses are not medically accepted indications for Botox therapy. You do not have a diagnosis of urinary incontinence, neurogenic detrusor overactivity or overactive bladder. There is not a diagnosis of pelvic floor dyssynergia, an off-label use. Myofascial pelvic floor dysfunction is not an FDA approved indication. The review has determined that the requested Botox is notmedically reasonable or 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 Botox have not been met.Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the myocardial perfusion nuclear stress test provided on December 18, 2020.

You asked the Plan to waive the deductible for the myocardial perfusion nuclear stress test. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient diagnostic services on the date of service at issue in this appeal. The Plan says that the correct amount has applied towards your deductible per your contract with the Plan.

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 $750 deductible that must be met before the Plan will pay their share for Outpatient diagnostic tests.

The item or service you asked the Plan to waive the deductible for falls within the benefit category Outpatient diagnostic tests. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $750 deductible that must be met before the Plan will pay their share for Outpatient diagnostic tests. This cost sharing is a contractual obligation that had not been met at the time the myocardial perfusion nuclear stress test was received on December 18, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the myocardial perfusion nuclear stress test provided on December 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on December 4, 2020, and December 5, 2020.
You asked the Plan to pay for the self-administered drugs. You say that you would like to appeal the self-administered drugs. The Plan denied your request. The Plan says that these drugs are not covered by 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 drugs provided on December 4, 2020, and December 5, 2020.
Benefits for the self-administered drugs 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on August 24, 2020.
You asked the Plan to pay for the psychotherapy services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for psychotherapy services provided on August 24, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a contact lens fitting (92310) provided on March 10, 2020.
You asked the Plan to pay for the contact lens fitting. You say that this service was necessary for your eyes. The Plan denied your request. The Plan says this service is not covered by Medicare or by the Plan's supplemental vision benefit.
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. We looked at the file and the Plan's rules. Although the Plan offers a supplemental vision benefit in excess of Medicare coverage, the requested service is not among those covered by this benefit. Therefore, we decided that the Plan does not have to pay for a contact lens fitting (92310) provided on March 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Evenity.

You asked the Plan to pre-approve a tier exception. You say that you would like assistance with the copay.The Plan denied your request. The Plan says that tier exceptions are not available for drugs/devices covered by Part B.

The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. 

The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met.Therefore, we decided that the Plan does not have to pre-approve a tier exception for Evenity.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of knee (73721)

You asked the Plan to pre-approve the MRI. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says there is no clinical documentation provided to substantiate the medical necessity of the requested examination.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record indicates that the enrollee had an acute injury that resolved in a month with conservative treatment. A recent evaluation for a shoulder injury does not indicate any issue with he knew. The available record does not support that an MRI if the knee is a medically necessary or reasonable service as defined by Medicare rules. The elements of the coverage criteria are not satisfied.

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of knee (73721).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued SNF services. You say that the SNF services continue to be medically necessary. The Plan denied your request. The Plan says coverage criteria is no longer met.
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 continued SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the patient has no complex wound care or other skilled nursing need. The enrollee's therapy needs do not require the specialized skill, knowledge and judgment of a qualified therapist. Skilled therapy is not required on a daily basis. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF stay.
You asked the Plan to pre-approve the SNF stay. You say that you do not have a safe disposition. The Plan denied your request. The Plan says the services requested are not reasonable and necessary for the treatment of your illness.
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 stay. 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 require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not have daily skilled therapy needs that require 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. Based on this information, we decided that Medicare rules for coverage of the SNF stay have not been met. Although you have skilled therapy needs, these needs are not on a daily basis. Therefore, we decided that the Plan does not have to pre-approve the SNF stay.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy services provided from October 1, 2020 to November 2, 2020.

You asked the Plan to waive the copayments for the physical therapy services. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received physical therapy services on the dates of service at issue in this appeal. The Plan says that the correct copayments have applied per your contract with the Plan.

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 Outpatient rehabilitation services.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received physical therapy services from October 1, 2020 to November 2, 2020. You have been asked to pay a $40 copayment for each physical therapy visit. The physical therapy services fall within the Outpatient rehabilitation services benefit category. This means that you have been asked to pay the correct amounts 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 the physical therapy services provided from October 1, 2020 to November 2, 2020.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to reduce the cost for the test materials. We decided that the Plan does not have to waive the cost for the test materials.
You asked the Plan to waive the cost for the test materials. You say that you do your own tests at home not in the doctor's office. The Plan says that the copayments applied correctly.
We decided that the Plan has to reduce the cost for the test materials.
The test materials are considered a medical supply not a physician service. The Plan contract clearly says that enrollees pay 20% coinsurance for medical supplies from an in-network provider. Therefore, we decided the Plan has to reduce the cost for the test materials from $50 for each date of service to 20% of the allowed amount for each date of service.
We also decided that the Plan does not have to waive the cost for the test materials.
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 medical supplies from an in-network provider. Therefore, we decided that the Plan does not have to waive the cost for the test materials.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injection services provided on February 12, 2020 by an out of network (OON) provider.
You asked the Plan to pay for injection services. You say that the enrollee originally provided the incorrect insurance information to you, which caused you to be unable to obtain prior authorization. The Plan denied your request. The Plan says the denial of payment for these services 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 injection services provided on February 12, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit provided by an out-of-network provider on November 18, 2020.

You asked the Plan to pay for the home visit. You say that the doctor depends on the hospital staff to verify eligibility and obtain proper authorization. You say that the doctor should not be penalized the claim should be considered for payment.The Plan denied your request. The Plan says this provider is not a network provider with 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 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 the home visit provided by an out-of-network provider on November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110) provided on December 5, 2020.

You asked the Plan to pay for the dental services. You say that it is your understanding that you can have 2 periodic oral exams per year. You say that the last time you had a periodic oral exam was on January 4, 2020. You say that you believe that you are allowed 3 cleanings per year. You also say that you called the Plan on November 20, 2020 and was approved for all the services you were going to have on the date of service.The Plan denied your request. The Plan says 2 periodic oral exams per calendar year are covered. The Plan says that 2 prophylaxes per year are covered. The Plan also says that the frequency limits have been exceeded.

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 and the services are listed as covered, the frequency limits have been exceeded. The record shows that the Plan paid for these services that you received on June 9, 2020, and September 1, 2020.Therefore, we decided that the Plan does not have to pay for the periodic oral exam (D0120) and prophylaxis (D1110) provided on December 5, 2020.