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

We decided that the Plan does not have to waive the coinsurance for the chemotherapy injections provided from September 25, 2019 to October 30, 2019.
You asked the Plan to waive the coinsurance for the chemotherapy injections. You say that you are requesting reimbursement for the injections. 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 20% coinsurance for Part B drugs, including chemotherapy. You have been asked to pay a total of $191 which is 20% of the allowed amount for the chemotherapy injections. The chemotherapy injections fall within the "Medicare Part B prescription drugs" 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 coinsurance for the chemotherapy injections provided from September 25, 2019 to October 30, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitationfacility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the records provided support the need for care in an IRF.The Plan denied your request. The Plan says the clinical information received does not show that the guidelines for coverage have been met. The Plan says that the enrollee's condition is not medically complex and she does not require the close supervision by a rehabilitation doctor. The Plan says that the enrollee's needs can safely be met in a skilled nursing facility setting.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 enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's current medical status does not require intensive physician or nursing oversight in an IRF. The enrollee may benefit from additional multiple therapies, however the enrollee'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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebone marrow aspiration for bone grafting (20939).You asked the Plan to pre-approvebone marrow aspiration for bone grafting. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 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 bone marrow aspiration for bone grafting. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no specific indication provided to support the request for bone marrow aspiration for the approved surgery. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of bone marrow aspiration in conjunction with the lumbar surgery performed. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for this enrollee's medical condition. Therefore, the request for bone marrow aspiration is not medically reasonable and necessary for the approved lumbar fusion.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bonemarrow aspiration for bone grafting have not been met.Therefore, we decided that the Plan does not have to pre-approvebone marrow aspiration for bone grafting (20939).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup for the enrollee.You asked the Plan to pre-approve the dental services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered 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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve core buildup for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the duplex scan provided on January 27, 2020.You asked the Plan to waive the copayment forthe duplex scan. You say that no scans have had this copayment before. You say that the copayment should be $20.The Plan denied your request. The Plan says the copayment applied 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 $150 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $150 copayment for the duplex scan. The duplex scan falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The duplex scan is considered an ultrasound. 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 duplex scan provided on January 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided on January 20, 2020 by an OON provider.
You asked the Plan to pay more for the prophylaxis and periodic oral evaluation. You say that the Plan paid your claim at 50% of what an in-network dentist would have been paid. You also say that the Plan should have paid $92 instead of $46. The Plan denied your request. The Plan says these services were performed by a non-participating provider. The Plan also says that you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for the services.
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, you are responsible for a 50% coinsurance for covered dental services that are received OON. The Plan is only responsible for paying 50% of the allowed amount for services that are received OON. Therefore, we decided that the Plan does not have to pay more for the prophylaxis and periodic oral evaluation provided on January 20, 2020 by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on October 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
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 who can provide 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 medical services provided to the enrollee by an out-of-network provider
on October 11, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve outpatient mental health care out of network.
You asked the Plan to pre-approve out of network services. You say that you prefer to see the requested provider. The Plan denied your request. The Plan says the requested provider is out of network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must 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 is not in network. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve outpatient mental health care out of network.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on December 5, 2019.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not include a valid physician order, laboratory requisition, or medical records to support the service billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on December 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freedom Bed (E1399).
You asked the Plan to pre-approve the Freedom Bed. You say that you would like reconsideration because the member experiences pain and discomfort in their current bed. The Plan denied your request. The Plan says a total electric bed is not a benefit of the Medicare program or health plan.
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 includes convenience features that are not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a Freedom Bed (E1399).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee..
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the request is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee still requires acute level of care hospital services and is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets all of the criteria for admission to an LTACH. The Plan denied your request. The Plan says the records received do not indicate that the criteria for coverage have been met. The Plan says that the enrollee can safely receive the care needed in another setting. The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for acute-on-chronic renal failure following a recent to amputation. The enrollee was started on hemodialysis and appears to be showing signs of renal recovery. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the alveoloplasty not in conjunction with extractions provided on March 20, 2020.You asked the Plan to pay for the alveoloplasty. You say that this appointment was for a checkup and they removed some bony fragment that they left from your previous visit. You also say that your insurance plan told the facility that you did not want this service provided.The Plan denied your request. The Plan says this service is not a covered 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, 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 alveoloplasty not in conjunction with extractions provided on March 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the cone beam CT image capture (D0380) and problem
focused limited oral evaluation (D0140) provided on February 18, 2020.
You asked the Plan to pay for the cone beam CT image capture and problem focused limited oral evaluation.
You say that you were sent to this provider to try saving a molar tooth. You also say that the limited oral
evaluation was needed to determine the treatment for the tooth. The Plan denied your request. The Plan says
cone beam CT image capture is not a covered benefit under your dental plan. The Plan also says that the
problem focused limited oral evaluation exceeds the frequency limitation in your benefit 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, cone beam CT image capture is not
among those covered under this benefit. The contract also clearly states that problem focused limited oral
evaluation (D0140) is limited to one procedure per plan year. The record shows that you received a problem
focused limited oral evaluation on January 30, 2020 and your problem focused limited oral evaluation has been
exhausted. Therefore, we decided that the Plan does not have to pay for the cone beam CT image capture
(D0380) and problem focused limited oral evaluation (D0140) provided on February 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walker.You asked the Plan to pre-approve a walker. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested item is a duplicate to an item you already have.The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a walker. The walker you currently have serves the same purpose as a walker. Review of the file shows that you received your current walker in 2018. The reasonable useful lifetime of this item is no less than five years. You have not had your current walker for five years. Additionally, the documentation does not support that you have had an evaluation from a DME provider that states your current walker is irreparable. Therefore, we decided that the Plan does not have to pre-approve a walker.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on February 14, 2020.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was applied 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 $225 copayment for each in-network Medicare-covered outpatient hospital facility visit.
Review of the file shows that you received outpatient hospital services on February 14, 2020. You have been asked to pay a $225 copayment for these services. These services fall within the in-network Medicare-covered outpatient hospital facility 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 the outpatient hospital services rendered on February 14, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on February 13, 2020.
You asked the Plan to pay for drug tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support a valid order for these tests.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on February 13, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveCarboplatin (J9045), Ondansetron HCL (J2405), Dexamethasone Sodium Phosphate (J1100), and Fosaprepitant (J1453).You asked the Plan to pre-approveCarboplatin, Ondansetron HCL, Dexamethasone Sodium Phosphate, and Fosaprepitan. You say that the enrollee has previously used Carboplatin with other medications.The Plan denied your request. The Plan says that this combination is not supported for the enrollee's specific cancer.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 Carboplatin, Ondansetron HCL, Dexamethasone Sodium Phosphate, and Fosaprepitan. Our reviewer says that the requested use of these drugs meets criteria for coverage. Our physician reviewer found this use is supported in the Lexicomp drug compendium and the documentation supports that the requested drug is safe and effective and otherwise 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 Carboplatin, Ondansetron HCL, Dexamethasone Sodium Phosphate, and Fosaprepitan have been met.Therefore, we decided that the Plan has to pre-approveCarboplatin (J9045), Ondansetron HCL (J2405), Dexamethasone Sodium Phosphate (J1100), and Fosaprepitant (J1453).