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

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on November 16, 2019.You asked the Plan to waive the copayment for a colonoscopy. You say that you disagree with the charges because this was a screening colonoscopy.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 $400 copayment for outpatient hospital facility services.The medical records show that you received a colonoscopy due to an abnormal CT scan result. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $400 copayment. You have been asked to pay a $400 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 colonoscopy provided on November 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hyperbaric oxygen (HBO) therapy (99183) provided on August 8, 2019.
You asked the Plan to pay for HBO therapy. You say that this was medically necessary. The Plan denied your request. The Plan says the enrollee has skin ulcers.
The Plan follows Medicare rules. Medicare rules say that HBO therapy is not covered for the treatment of cutaneous, decubitus, and stasis ulcers or chronic peripheral vascular insufficiency. 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 pay for HBO therapy. Our reviewer says that the criteria for coverage of HBO therapy have not been met. Our physician reviewer found the records show that the enrollee has painful skin ulcers of the extremities, torso, pannus, and penis and calciphylaxis. This description best is described by the non-covered "cutaneous, decubitus, and stasis ulcers" condition category as well as the non-covered "chronic peripheral arterial insufficiency" category. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not have to pay for hyperbaric oxygen (HBO) therapy (99183) provided on August 8, 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-approveIRF care. The Plan denied your request. The Plan says IRF admission 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 above.We asked our physician reviewer to carefully review the case file and apply therelevant 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 that 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 medical status does not require intensive IRF physician or nursing supervision. The enrollee may benefit and participate from multiple therapies such as physical therapy and occupational therapy, however the documentation does not support that this enrollee's current functional status and weight bearing restrictions require intensive rehabilitation therapy program provided in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET scan for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans 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 scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found CMS criteria for PET imaging of the brain for memory loss specifies that the memory loss must be quantified and have an onset within the past 6 months. In addition, there must be a possibility of Fronto-temporal dysplasia in the differential. These criteria are not met thus according to CMS guidelines the medical necessity for PET brain imaging is not established. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET scan for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve OneTouch Verio test strips.You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee is using the OneTouch Verio test strip brand.The Plan denied your request. The Plan says the non-preferred brand is not deemed medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. There is no documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met.Therefore, we decided that the Plan does not have to pre-approve OneTouch Verio test strips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab services provided to the enrollee on November 19, 2019.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.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 billing provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 forlab services provided to the enrollee on November 19, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent hospital care provided on September 19, 2019.
You asked the Plan to pay for the subsequent hospital care. The Plan denied your request. The Plan says in accordance with Medicare guidelines, the provider needs to bill Original Medicare, using the proper modifiers, for services rendered on September 19, 2019.
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 subsequent hospital care provided on September 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra heavy duty hospital bed.
You asked the Plan to pre-approve the bed. You say that this is medically necessary. The Plan denied your request. The Plan says your weight is under the required weight of 600 pounds.
The Plan must follow Medicare rules. The rules say that an extra heavy duty hospital bed is covered for enrollees over 600 pounds. The enrollee's weight is 353 pounds, which is under the required weight for this particular bed. Based on this information, we decided that Medicare rules for coverage of the bed have not been met. Therefore, we decided that the Plan does not have to pre-approve an extra heavy duty hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hyperbaric oxygen (HBO) therapy (99183) provided on August 1, 2019.You asked the Plan to pay for HBO therapy. You say that this was medically necessary.The Plan denied your request. The Plan says the enrollee has skin ulcers.The Plan follows Medicare rules. Medicare rules say that HBO therapy is not covered for the treatment of cutaneous, decubitus, and stasis ulcers or chronic peripheral vascular insufficiency.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 pay for HBO therapy. Our reviewer says that the criteria for coverage of HBO therapy have not been met. Our physician reviewer found the records show that the enrollee has painful skin ulcers of the extremities, torso, pannus, and penis and calciphylaxis. This description best is described by the non-covered "cutaneous, decubitus, and stasis ulcers" condition category as well as the non-covered "chronic peripheral arterial insufficiency" category.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met.Therefore, we decided that the Plan does not have to pay for hyperbaric oxygen (HBO) therapy (99183) provided on August 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on October 17, 2019.
You asked the Plan to waive the copayment for arthrocentesis. You say that you did not receive a surgical
procedure and disagree with the charges. The Plan denied your request. The Plan says the claims were
processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $290
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You received arthrocentesis on October 17, 2019. Arthrocentesis is considered an outpatient surgical
procedure, therefore, you are responsible to pay the allowed amount of $280.25, which is less than the $290
copayment.
You have been asked to pay $280.25 for arthrocentesis. Arthrocentesis falls within the outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 arthrocentesis provided on October 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the DME items provided on November 3, 2019.
You asked the Plan to pay for the DME items. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 DME items at issue. We found no exception that would require the Plan to pay for these items. Therefore, we decided that the Plan does not have to pay for the DME items provided on November 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prism ceiling lift repair (E1399).You asked the Plan to pre-approvePrism ceiling lift repair. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says this requested service is does not meet the criteria for medical necessity.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The plan says that the requesting vendor has not explained what is specifically broken, what requires repair and has not responded with the requested necessary additional information. Based on this information, we decided that Medicare rules for coverage of Prism ceiling lift repair have not been met.Therefore, we decided that the Plan does not have to pre-approvePrism ceiling lift repair (E1399).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enhertu for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says gastric cancer is not an FDA-approved indication for this drug.
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 the drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found Enhertu is not FDA
approved and is not supported by any of the CMS approved compendia. The submitted documentation does not
support that the Enhertu is medically reasonable and necessary for the enrollee. The documentation does not
support that the Enhertu is safe and effective for the 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 the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Enhertu for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedical services to be provided by an out-of-network provider.You asked the Plan to pre-approvethe services. The Plan denied your request. The Plan says the services are not urgent/emergent.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.Therequested 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. 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-approvemedical services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided to enrollee by an out of network (OON) provider.You asked the Plan to pre-approvethe OON services. You say that failure to under therapy will have serious consequences to the enrollee.The Plan denied your request. The Plan says an in-network provider can provide the requested services.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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services. Therefore,we decided that the Plan does not have to pre-approvethe medical services to be provided to enrollee 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 office visit provided on November 8, 2019 and December 2, 2019.
You asked the Plan to waive the copayment for the office visit. You say that you were informed there would be no charge. 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 $45 office visit copayment if services are provided by a specialist. You have been asked to pay a $45 copayment for each office visit. The total amount you owe is $90 ($45/visit x 2 visits = $90). The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the office visits were with a specialist. 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 office visit provided on November 8, 2019 and December 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve coverage for over-the-counter benefits.
You asked the Plan to pre-approve over-the-counter benefits. You say that you feel that you pay a lot of money for your policy and that your benefits should include over-the-counter benefits, The Plan denied your request. The Plan says over-the-counter benefits is not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items. Therefore, we decided that the Plan does not have to pre-approve coverage for over-the-counter benefits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve life alert system.You asked the Plan to pre-approve life alert system. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says this item is considered a convenience device and not a covered benefit.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 available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approve life alert system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Novolog Mix 70/30 Flexpen injections for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this medication falls under Part D coverage - however, the enrollee does not have a Part D pharmacy benefit.
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 Novolog Mix 70/30 Flexpen injections for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 27, 2019 by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-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 referring provider 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. 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 medical services provided on September 27, 2019 by a non-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe SNF stay provided from August 21, 2019 through September 28, 2019.You asked the Plan to waive the copayment forthe SNF stay. You say that he was kept at the facility even though he met qualifications to go home.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $0 copayment per day for days 1 through 20 and a $170.50 copayment per day for days 21 through 100. The enrollee has been asked to pay a $2,562.37, which is less than the standard copaymentfor the SNF stay because the enrollee met the maximum out-of-pocket. The SNF stayfalls within the "Skilled nursing facility (SNF) 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 forthe SNF stay provided from August 21, 2019 through September 28, 2019.