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

We decided that the Plan does not have to waive the copayment fora spinal canal injection provided on August 13, 2019.You asked the Plan to waive the copayment fora spinal canal injection. You say that you 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 $0 copayment for any surgical procedure during a colorectal screening and a $200 copayment for all other outpatient services.You received a spinal canal injection on August 13, 2019. A spinal canal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $200 copayment.  You have been asked to pay a $200 copayment for a spinal canal injection. A spinal canal injection 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 fora spinal canal injection provided by on August 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Premarin tablets.
You asked the Plan to pre-approve Premarin tablets. You say that this is necessary to treat the enrollee's hot flashes and prevent osteoporosis. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug plan.
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 Premarin tablets.
Benefits for Premarin tablets may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for eye therapy services received from September 26, 2018 to December 18, 2018.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for eye therapy services received from September 26, 2018 to December 18, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Tadalafil 5mg tablet medication.
You asked the Plan to pre-approve this medication. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the member's policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Tadalafil 5mg tablet medication.
Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a post radiation oncology visit to be provided.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services. Therefore, we decided that the Plan does not have to pre-approve physician's services for a post radiation oncology visit to be provided.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided July 7, 2019 through July 9, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the hospital previously submitted a claim for payment for post-stabilization services to the Medicare Advantage patient identified above. The non-contracted payer has inappropriately denied the claim from July 7, 2019 to July 9, 2019. The Plan denied your request. The Plan says that this determination is not medically necessary. Based upon the documentation there was no obvious expectation of need for more than 2 overnights and as such deny admission but approve as observation.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee presented to the emergency department (ED) on July 7, 2019 from his board-and-care facility complaining left-sided chest pain gradually worsening with fatigue and weakness. The reviewer has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided July 7, 2019 through July 9, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility services for the enrollee.
You asked the Plan to pre-approve continued services. You say that it is not safe for the enrollee to be sent home. The Plan denied your request. The Plan says the enrollee has exhausted the skilled nursing facility benefit.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from July 25, 2019 to January 11, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel sureclick injections.
You asked the Plan to pre-approve Enbrel sureclick injections. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says Enbrel sureclick injections are not covered under the enrollee's Medicare Part B benefit. The Plan says they believe the enrollee's pharmacy benefit manager is X.
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 Enbrel sureclick injections.
Benefits for Enbrel sureclick injections may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided.
You asked the Plan to pre-approve the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on October 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says you must receive your care from a network provider.
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 you by an out-of-network provider on October 22, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a platelet-rich plasma injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare does not consider CPT 0232T to be medically reasonable or necessary. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a platelet-rich plasma injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bevacizumab injections into the eye (J9035, 67028).
You asked the Plan to pre-approve Bevacizumab injections into the eye. You say that the requested medication is 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. 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 Bevacizumab injections into the eye. Our reviewer says that the service is not medically necessary. Our physician reviewer found review of Medicare compendia does not support the use of Bevacizumab for the treatment of this diagnosis. Without the support of the compendia, medical necessity cannot be determined. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Bevacizumab injections into the eye have not been met. Therefore, we decided that the Plan does not have to pre-approve Bevacizumab injections into the eye (J9035, 67028).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 18, 2019 by an out of network (OON) 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 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 18, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a wedge cushion.
You asked the Plan to pre-approve a wedge cushion. You say that the enrollee has an imbalance and needs a wedge cushion while using the wheelchair and for bed positioning. The Plan denied your request. The Plan says a wedge cushion does not serve a medical purpose.
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 a wedge cushion.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pre-approve these services. We decided that the Plan does not have to pre-approve .
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan says that the services are not covered.
We decided that the Plan has to pre-approve a third opinion.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules say that in the event that the recommendation of the first and second physician differs regarding the need for surgery (or other major procedure), a third opinion is also covered. We looked at the file and Medicare rules. The Plan has not made reasonable and diligent efforts to gather and
forward to us information regarding their decision to deny your request. The Plan states that a third opinion from the clinic is not covered because you have been evaluated on two previous occasions by your physician, who stated that the referral would not likely be helpful. Medicare allows a third opinion if the recommendations of a first and second physician differ. The Plan has not provided documentation to show that you have been seen by two different physicians regarding your condition and that their opinions did not differ. MAXIMUS requested this information from the Plan, but the response contained medical records from the first physician only. The Plan has not provided any documentation to support that at third opinion is not covered per Medicare rules. Therefore, we decided that the Plan has to pre-approve these services.
We also decided that the Plan does not have to pre-approve a third opinion at the clinic.
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. A third opinion is available from network provider. Therefore, we decided that the Plan does not have to pre-approve a third opinion at the clinic.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on October 1, 2019.
You asked the Plan to pay for the hospital outpatient clinic visit. 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 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 hospital outpatient clinic visit provided on October 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a heavy duty manual wheelchair.
You asked the Plan to pre-approve a heavy duty manual wheelchair. You say that the enrollee needs a manual wheelchair for appointments. The Plan denied your request. The Plan says only one wheelchair at a time is covered.
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 the enrollee has a power wheelchair. This power wheelchair serves the same purpose as a heavy duty manual wheelchair. Medicare only covers one wheelchair at a time. Medicare does not cover wheelchairs for outside the home use only. Therefore, we decided that the Plan does not have to pre-approve a heavy duty manual wheelchair.
Appeal type: Transportation
Decision: Partially Favorable

We decided that the Plan has to reduce the coinsurance for the ambulance transports. We decided that the Plan does not have to waive the coinsurance for the ambulance transports.
You asked the Plan to waive the coinsurance for the ambulance transports. You say that you cannot afford to pay these bills. The Plan says that the coinsurance applied correctly.
We decided that the Plan has to reduce the coinsurance for the ambulance transports.
Your contract with the Plan clearly says that you must pay 20% coinsurance for ambulance transports. The Plan says that you must pay a total of $303.73 for the ambulance transports. Based on the Plan contract however, you cannot be asked to pay more than $238.13 for the ambulance transports.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
May 20, 2019
Ambulance Transport
$400.84
20%
$80.17
May 29, 2019
Ambulance Transport
$394.92
20%
$78.98
June 5, 2019
Ambulance Transport
$394.92
20%
$78.98
TOTAL:
$238.13
Therefore, we decided that the Plan has to reduce the coinsurance for the ambulance transports.
We also decided that the Plan does not have to waive the coinsurance for the ambulance transports.
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 regardless of the number of trips for ground ambulance services. Therefore, we decided that the Plan does not have to waive the coinsurance for the ambulance transports.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Metformin HCL ER 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 the enrollee has a medical only policy with X.
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 Metformin HCL ER for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the routine hearing exam and hearing aids.
You asked the Plan to pre-approve routine hearing exam and hearing aids. You say that you are requesting an exception for coverage for hearing exam and hearing aids. The Plan denied your request. The Plan says the requested services is not covered under the benefit package.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though routine hearing exam and hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pre-approve the routine hearing exam and hearing aids.