Persius/hicric huggingface dataset:
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 service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 enrollee's medical conditions are stable and there are no complex nursing or rehabilitation needs. While the documentation does support a need for physical and/or occupational therapy,
there is no documented need for a intensive, multi-disciplinary rehabilitation 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. Specifically, medically necessary services can be obtained at a lower level of care. This means admission into an IRF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal cord stimulator.
You asked the Plan to pre-approve a spinal cord stimulator. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.
The Plan follows Medicare rules. Medicare rules say that a spinal cord stimulator is subject to the coverage criteria listed in the Medicare rules section. 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 spinal cord stimulator. Our reviewer says that the requested procedure is not medically reasonable and necessary. Our physician reviewer found the enrollee is a 66-year-old man who has chronic neck pain that radiates to his shoulders. In this case, the enrollee does not have an evidence-based indication for a spinal cord stimulator trial. There is no indication for this procedure. The request is not medically 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 a spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal cord stimulator.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received 
from April 25. 2021, to April 27, 2021. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you are disputing 
this copayment.  You did not provide any specifics regarding your dispute. The Plan denied your request. The 
Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $295 
copayment per admission for inpatient hospital care.  
 
You have been asked to pay a $295 copayment for the inpatient hospital services. 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 services you received from April 25. 2021, to April 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network provider.

You asked the Plan to pre-approve these services. You say that you are in need of pain management services. The Plan denied your request. The Plan says the services are available from network providers.

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 a referral to an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (G0480, 80307) provided on February 8, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for drug testing. You say that you would like the claim reviewed and reconsidered. The Plan denied your request. The Plan says services were provided by an out-of-network provider without 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 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 drug testing (G0480, 80307) provided on February 8, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urology office visit you had on May 10, 
2021. 
 
You asked the Plan to waive the copayment for the urology office visit. You say that you should not have to 
pay a second copayment because this visit was just a follow-up from a PSA test you had. The Plan denied your 
request. The Plan says you were charged this copayment correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 
copayment for visits with a specialist.  
 
You have been asked to pay a $30 copayment for the urology office visit. Visits that are follow-up visits from 
tests are separately payable and the copayment is not included in the cost for the test. 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 urology office visit you had on May 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from May 18, 
2021, to May 20, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you did not have a 
private room and should not be charged for the stay. 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 $300 
copayment for days 1-5 for inpatient hospital care.  
 
You had an inpatient hospital stay from May 18, 2021, to May 20, 2021. Therefore, you are responsible to pay 
a $300 copayment for days 1-2 (May 18, 2021, to May 19, 2021). The total amount you owe is: $300 (copayment) x 2 (inpatient days) = $600.  
 
You have been asked to pay the total copayment amount of $600 for an inpatient hospital stay. An inpatient 
hospital stay falls within the inpatient hospital 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 inpatient hospital stay from May 18, 2021, to May 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to be reimbursed an additional amount for eyewear provided on
April 1, 2021.
You asked the Plan to be reimbursed an additional amount for the eyewear. The Plan denied your request. The Plan says that the Plan's vision care provider already reimbursed you $90 towards your eye wear purchase.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine 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. The file shows that you were reimbursed the correct amount based on the Plan's eyewear benefit. Therefore, we decided that the Plan does not have to be reimbursed an additional amount for eyewear provided on April 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aimovig 140mg/mL auto-injectors. 
 
You asked the Plan to pre-approve the Aimovig. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says this self-administered drug is 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 pre-approve Aimovig 140mg/mL auto-
injectors.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.

You asked the Plan to pre-approve compression stockings. You say that compression stockings are medically necessary for treatment of venous insufficiency. The Plan denied your request. The Plan says Medicare coverage criteria are not met as the requested stockings are not covered for your condition.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on December 24, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the
member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all
hospice care from the effective date of election to the date of discharge or revocation.

During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to
the terminal illness until the first day of the month following the month in which hospice was revoked or
discharged.

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.

The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for physician's services provided on December 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block.
You asked the Plan to pre-approve a genicular nerve block. You say that the requested genicular nerve block is medically necessary. The Plan denied your request. The Plan says the requested genicular nerve block 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 a genicular nerve block. Our reviewer says that the requested genicular nerve block is not medically necessary. Our physician reviewer found the requested genicular nerve block is considered an experimental/investigational procedure. The procedure is undergoing clinical trials and the enrollee is not part of a clinical trial. Therefore, the request is considered not medically 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 a genicular nerve block have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an outpatient hospital facility visit provided 
on January 15, 2021. 
 
You asked the Plan to waive the deductible for an outpatient hospital facility visit. You say that this was a 
telehealth visit and you should not owe a deductible for an office 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. Your 
contract with the Plan says that there is a $750 deductible for outpatient surgery, including services provided at 
hospital outpatient facilities. 
 
The record shows that you received services from an outpatient hospital facility on January 15, 2021. 
Therefore, you are responsible to pay your share of the cost-sharing charges. You had only paid $113 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of 
$47.50.   
 
The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan 
has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost 
sharing is a contractual obligation that had not been met at the time an outpatient hospital facility visit was 
received on January 15, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an 
outpatient hospital facility visit provided on January 15, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the virtual behavioral health visit you had with an out-of-network provider on May 10, 2021.
You asked the Plan to waive the copayment for the virtual behavioral health visit you had with an out-of-network provider. You say that virtual visits should have a $0 copayment. The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for outpatient mental health care visits with an out-of-network specialist. You have the option of
receiving these services either through an in-person visit or via telehealth. If you choose to receive one of these services via telehealth, then you must use a network provider that currently offers the service via telehealth. You have been asked to pay a $40 copayment for the virtual behavioral health visit you had with an out-of-network provider. Your Evidence of Coverage states that telehealth visits for mental health care are only covered at $0 if you use a network provider. The provider you saw is an out-of-network provider, so that is why you were appropriately charged a specialist copayment. 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 virtual behavioral health visit you had with an out-of-network provider on May 10, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda (J9271), Carboplatin (J9045), and pemetrexed (J9305).
You asked the Plan to pre-approve Keytruda, carboplatin, and pemetrexed. You say that the requested regimen is medically necessary. The Plan denied your request. The Plan says the requested regimen is not necessary in the clinical scenario and guidance in this case.
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 Keytruda, carboplatin, and pemetrexed. Our reviewer says that the requested chemotherapy regimen is not medically necessary. Our physician reviewer found the requested regimen is not FDA approved for the enrollee's diagnosis. The reviewer found that the enrollee has progressed on immunotherapy with duvalumab. The reviewer found that the enrollee has previously received carboplatin and pemetrexed.
The reviewer also found that the use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal (see appendix for list of CMS-approved journals). Therefore, the reviewer found that the requested chemotherapy regimen is not medically 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 Keytruda, carboplatin, and pemetrexed have not been met. Specifically, the file shows that the requested regimen is not approved by the FDA for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271), Carboplatin (J9045), and pemetrexed (J9305).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic, prophylactic, or diagnostic injection (96372), office visits (99204, 99214), and the additional supplies, materials, and clinical staff time over and above those usually included in an office visit (99072) rendered by the out-of-network (OON) provider from October 8, 2020, through November 17, 2020.

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 the services were rendered by an out of network provider, without 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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. 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 the therapeutic, prophylactic, or diagnostic injection (96372), office visits (99204, 99214), and the additional supplies, materials, and clinical staff time over and above those usually included in an office visit (99072) rendered by the out-of-network (OON) provider from October 8, 2020, through November 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a raised toilet seat and a shower chair.
You asked the Plan to pre-approve the raised toilet seat and a shower chair. You say that the supplies are
necessary. The Plan denied your request. The Plan says these items are not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs and raised toilet seats are not
covered because they are not primarily medical in nature.
While these supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a raised toilet seat and a shower chair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on May 7, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you spoke to a nurse practitioner on the phone about an upcoming surgery and this shouldn't warrant a copayment. 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 specialist visits, including telehealth visits. The record shows that you received telehealth specialist services on May 7, 2021. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 specialist visit provided on May 7, 2021.