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

We decided that the Plan does not have to waive the coinsurance forthe Rituxaninjections provided from September 24, 2019 to October 15, 2019.You asked the Plan to waive the coinsurance forthe injections. The Plan denied your request. The Plan says that these processed with less than the applicable coinsurance amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for the injections. The 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 forthe Rituxan injections provided from September 24, 2019 to October15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crutch substitute (CPT Code E0118), for the enrollee.You asked the Plan to pre-approve the DME. You say that it is medically necessary for the enrollee to be provided with a knee scooter.The Plan denied your request. The Plan says this item is not covered under Medicare or the Health Plan.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. This item is not covered under Medicare or the Health Plan.Therefore, we decided that the Plan does not have to pre-approve crutch substitute (CPT Code E0118), for the enrollee
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve UPWalker, for the enrollee.You asked the Plan to pre-approve the walker. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says an upgrade is an item that exceeds the legitimate medical needs of a person. The Plan states upgrades primarily provide comfort or convenience.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 purposethat 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. Medicare says that items are covered if they are reasonable and necessary to serve the intended purpose. The UPWalker is an upgraded device. An upgrade is an item that exceeds the legitimate medical needs of a person. Upgrades primarily provide comfort or convenience.Therefore, we decided that the Plan does not have to pre-approve UPWalker, for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Positron Emission Tomography (PET) scan (78815) provided on March 11, 2019.
You asked the Plan to waive the coinsurance for the PET scan. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Diagnostic Radiology. You have been asked to pay a 20% coinsurance for the PET scan. The PET scan falls within the Diagnostic Radiology 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 a Positron Emission Tomography (PET) scan (78815) provided on March 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the DME provided to the enrollee on and October 22, 2019.You asked the Plan to waive the coinsurance forthe DME. You say that the kits were always given without a copay.The Plan denied your request. The Plan says the claims were processed accordingly with the member's 2019EOC benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that the enrollee received DME provided to the enrollee on October 22, 2019. The enrollee is asked to pay 10% coinsurance per date ofservice for the DME. 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 coinsurance forthe DME providedto the enrollee on and October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fordiagnostic imaging and lab services provided on May 22, 2019 to June 29, 2019 by an out of network (OON) provider.You asked the Plan to pay fordiagnostic imaging and lab services. You say that you would like this appeal reprocessed and approved for payment.The Plandenied your request. The Plan says no prior authorization was 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 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 fordiagnostic imaging and lab services provided on May 22, 2019 to June 29, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit on November 1, 2019 at provider.You asked the Plan to waive the copayment for the Emergency Room visit. You say that the copayment should be waived.The Plan denied your request. The Plan says the cost sharing 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 $90 copayment for Emergency Care. You have been asked to pay a $90 copayment for the Emergency Room visit. The Emergency Room visit falls within the Emergency 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 foran Emergency Room Visit on November 1, 2019 at provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral wrist hand orthoses (L3916) provided to the enrollee on December 12, 2019.You asked the Plan to pay for the orthoses. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the medical records do not support this service.We asked our physician reviewer tocarefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthoses. Our reviewer says that the enrollee does not meet criteria for the orthoses ordered. Our physician reviewer found the documentation in the case file does not support that the requested wrist/hand orthoses were medically reasonable and necessary for the enrollee in this case. The physical exam documents no joint effusion, no joint swelling, no joint deformities. There is no documentation of a need for wrist/hand orthoses. The documentation does not support that the wrist/hand orthoses were medically reasonable and necessary in this case.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 orthoses have not been met.Therefore, we decided that the Plan does not have to pay forbilateral wrist hand orthoses (L3916) provided to the enrollee on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided to the enrollee on September 13, 2018.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says claims must be submitted within the 12 month time frame of services rendered.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the services was not filed until October 11, 2019.. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for office visit services provided to the enrollee on September 13, 2018.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya 100 mg/ml syringe (J3245).You asked the Plan to pre-approve Ilumya 100 mg/ml syringe. You say that the medication is necessary.The Plan denied your request. The Plan says based on the documentation provided,coverage criteria for a step therapy exception has not been met.Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.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    Ilumya 100 mg/ml syringe. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 Ilumya 100 mg/ml syringe have not been met.Therefore, we decided that the Plan does not have to pre-approve Ilumya 100 mg/ml syringe (J3245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on December 6, 2019 by a non-contracted provider.
You asked the Plan to pay for the hearing aids. You say that you were not aware of an out-of-network provider and you are requesting reimbursement for the hearing aids purchased. The Plan denied your request. The Plan says you do not have out-of-network benefits.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid 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. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. The provider is not in-network and your EOC clearly states, you must see a provider to use this benefit. Therefore, we decided that the Plan does not have to pay for hearing aids purchased on December 6, 2019 by a non-contracted provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.You asked the Plan to pre-approve the admission. You say that this is medically necessary.The Plan denied your request. The Plan says the plan has no contractual obligation to cover services that are not medically necessary, or that do not meet the criteria for SNF coverage.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. The enrollee does not have evidence of tracheostomy tube, new enteral feedings, complex wound care, or other SNF level skilled nursing need. The enrolleehas no symptoms related to COVID per documentation. The documentation does not reveal therapy documentation from PT or OT. The documentation does not support that the enrolleerequires skilled therapy. The enrolleedoes not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. The skilled nursing or skilled therapy services (or a combination of these services) are not needed on a "daily basis" in a SNF.Asa practical matter this enrolleedoes not require the necessary services on an inpatient basis, in a skilled nursing facility 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 admission have not been met.Therefore, we decided that the Plan does not have to pre-approveadmission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the diagnostic testing you received on September 24, 2019.You asked the Plan to waive the cost share for the testing services. You say that this was part of your annual check-up.The Plan denied your request. The Plan says the claim was processed correctly based on your plan benefits.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for diagnostic radiology services. The file shows that you received a digital breast tomo synthesis and diagnostic mammography services. You have been asked to pay a 20% coinsurance for the testing services. The tests fall within the outpatient diagnostic tests 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 cost share for the diagnostic testing you received on September 24, 2019.
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 November 5, 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 November 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Otezla 30mg tablet.You asked the Plan to pre-approve Otezla 30mg tablet. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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 Otezla 30mg tablet.Benefits for Otezla 30mg tablet 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on November 6, 2019.You asked the Plan to pay for the orthoses and sleeves. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the medical records do not support this service.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 the orthoses and sleeves. Our reviewer says that the enrollee does not meet criteria for the orthoses and sleeves ordered. Our physician reviewer found the documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is no objective documentation of joint laxity.The item coded L2397 (sleeve) is not separately payable when the base item is not covered.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 orthoses and sleeves have not been met.Therefore, we decided that the Plan does not have to pay for bilateral knee orthoses (L1833) and suspension sleeves (L2397) provided to the enrollee on November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics provided by provider.You asked the Plan to pay for foot orthotics. You say that you have difficulty walking because of a lump on your foot and the orthoses were recommended by your podiatrist.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pay for foot orthotics provided by provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve walker, enclosed, four-sided frame, rigid or folding, wheeled with posterior seat (E0144).You asked the Plan to pre-approvethe DME. You say that you are requesting review of denial of services.The Plan denied your request. The Plan says this request is denied as not medically necessary. The Plan states this device contains features that are for comfort and convenience and do not serve a medical purpose.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DMEhave not been met. The rules say that the medical necessity for a walker with an enclosed frame (E0144) has not been established. Therefore, if an enclosed frame walker is provided, it will be denied as not reasonable and necessary.Therefore, we decided that the Plan does not have to pre-approve walker, enclosed, four-sided frame, rigid or folding, wheeled with posterior seat (E0144).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the endodontic therapy of a premolar tooth (D3320) provided on to August 15, 2019.
You asked the Plan to pay for the endodontic therapy. You say that the enrollee's oral health care problems are very serious and are directly related to damage caused by radiation therapy. You also say that these services are medically necessary. 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 endodontic therapy of a premolar tooth (D3320) provided on to August 15, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda.You asked the Plan to pre-approveKeytruda. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested drug is not medically necessary.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 Keytruda. Our reviewer says that the documentation does not support that the requested drug, Keytruda is medically reasonable or necessary. Our physician reviewer found your provider ordered 12 cycles at 21 day intervals in conjunction with Pembolizumabfor the treatment of endomentrial cancer. Review of Medicare compendia and publications does not support this treatment regimen. Without the support of the documentation, medical necessity cannot be determined. Therefore, you do not meet criteria for the requested drug.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytrudahave not been met.Therefore, we decided that the Plan does not have to pre-approveKeytruda.Benefits for Keytrudamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.