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

We decided that the Plan does not have to waive the cost share for the laboratory work provided from May 29, 2019 to November 2, 2019. You asked the Plan to waive the cost share for the laboratory work. You say that you used to pay $7.85 for your blood draw and now you are being charged $20. 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. Your contract with the Plan says that there is a $300 deductible that applies towards in-network laboratory services and a $20 copayment per day, per provided for in-network Medicare-covered lab services. The laboratory work you asked the Plan to waive the cost share for falls within "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible that applies towards in-network laboratory services and a $20 copayment per day, per provided for in-network Medicare-covered lab services. This cost sharing is a contractual obligation that had not been met at the time the laboratory work was received on May 29, 2019 to November 2, 2019. Therefore, we decided that the Plan does not have to waive the cost share for the laboratory work provided from May 29, 2019 to November 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown (D2750) provided on November 1, 2019.
You asked the Plan to pay for the crown. You say that you have had crowns done before and the Plan has not denied coverage for those. 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 crown (D2750) provided on November 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 6, 2019.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The Plan says that the copayment applies because services were rendered.
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 $125 copayment for Medicare-covered ambulance services per day. You have been asked to pay a $125 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered ambulance services per day 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 ambulance transport provided on November 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for Brovana. You asked the Plan to waive the cost share for Brovana. You say that there is no alternative drug. The Plan denied your request. The Plan says tier exceptions are not allowed for Part B medications. 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 Brovana. Brovana falls 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 cost share for Brovana.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 7, 2019.
You asked the Plan to pay for the dental service. You say that you were never told there was any charge for this service. The Plan denied your request. The Plan says limited oral evaluations are covered once per patient per provider. The Plan also says that the frequency limit has been exceeded.
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 frequency limit has been reached. The record shows the Plan previously paid for this service that you received on October 9, 2019. among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Belimumab (Benlysta) for the enrollee.
You asked the Plan to pre-approve Benlysta. You say that Benlysta is the best option for the enrollee. The Plan denied your request. The Plan says the records do not show that the enrollee has a positive antibody test, or is receiving a standard therapy.
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 Benlysta. Our physician reviewer found that the enrollee has a diagnosis of Systemic Lupus Erythematosus. The documentation does not support that Benlysta is medically reasonable and necessary for the enrollee. The documentation does not support that Benlysta 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 Benlysta have not been met. Therefore, we decided that the Plan does not have to pre-approve Belimumab (Benlysta) for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit for the evaluation and management of an established patient (99334) provided on September 19, 2019. You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were in-network providers that could provide the services at issue. 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 domiciliary or rest home visit for the evaluation and management of an established patient (99334) provided on September 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient office visit (99204) and scanning computerized ophthalmic diagnostic imaging (92134) provided November 1, 2019.
You asked the Plan to waive the copayment for the vision services. You say that You feel that the copay for the diagnostic services performed is an error. The Plan denied your request. The Plan says the correct cost shares was correctly 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 $77.04. for Vision care. The plan contract says you must pay $35 copay for each Medicare covered exam to treat an eye condition and $75 for each covered diagnostic procedure or test at a network doctor's office. You have been asked to pay $77.04 for the vision services. The plan applied the $35 and $42.04 (which is lower than the $75). The vision services fall within the Vision care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for outpatient office visit (99204) and scanning computerized ophthalmic diagnostic imaging (92134) provided November 1, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that your left leg is weak, but you want to get it stronger. The Plan denied your request. The Plan says you are at baseline.
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 physician reviewer found that known co-morbid conditions include secondary progressive multiple sclerosis (MS). Your hospital course included management of a non-MS flare (MRI and CT were negative) with intravenous steroids, and management of a urinary tract infection. Pain and muscle spasms were managed with medications. The complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are at standby assist for functional mobility. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a portable oxygen battery (E1399) provided on August 19, 2019. You asked the Plan to waive the coinsurance for the oxygen battery. You say that the coinsurance should be waived. The Plan denied your request. The Plan says the correct cost share 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 once the $750 deductible was met for Durable Medical Equipment when provided out-of-network. You have been asked to pay a 20% coinsurance for the oxygen battery supplied by an out-of-network supplier. The $750 deductible has not been met. 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 portable oxygen battery (E1399) provided August 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve quinine sulfate capsules. You asked the Plan to pre-approve quinine sulfate capsules. You say that this medication has worked for the enrollee in the past. 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 quinine sulfate capsules.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for targeted genomic sequence assay testing provided on September 3, 2019. You asked the Plan to pay for genetic test. You say that you do not have direct interaction with the enrollee prior to testing, and the treating physician ordered this test to assist in treatment decisions for the enrollee. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this testing was not medically necessary. 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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. 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 did not specify whether the ordering physician is in-network or out-of-network with the Plan. The documentation submitted does not show that prior notice was given that this test would not be covered. Without this information, we cannot determine whether the lab order made constitutes plan-directed care, which would justify coverage of this test. Therefore, the Plan has not shown that its decision to deny payment for this claim is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for targeted genomic sequence assay testing provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on August 9, 2019.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says that 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 August 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to you by an out-of-network provider on October 5, 2019.You asked the Plan to pay forthe services. You say that you did not know the provider was out-of-network.The Plan denied your request. The Plan says out-of-network services are not covered.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 forthe medical services provided to you by an out-of-network provider on October 5, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 17, 2019 to September 23, 2019 by an out of network (OON) provider.You asked the Plan to pay forphysician visit. You say that your physician is covered by the facility authorization and should not be held responsible for a lack of authorization.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring facility is also out-of-network with 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 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 haveto pay forthe medical services provided on September 17, 2019 to September 23, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services for the enrollee. You asked the Plan to pre-approveIRF care. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are 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 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on March 4, 2020 and had acute respiratory failure. He has generalized weakness and debility. He is now generally medically stable with no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or need for acute rehab nursing care. He may benefit from further therapy but does not require an intensive therapy program 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 for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveinpatient mental health care beyond March 11, 2020.You asked thePlan to pre-approvethe services. The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 services. Our reviewer says that the requested inpatient mental health care is not medically reasonable and necessary. Our physician reviewer found that this enrollee does not appear to require inpatient mental health treatment beyond the date in question as she is not a danger to herself or others and does not have any auditory or visual hallucinations while being cooperative with treatment. It does not appear that active treatment istaking place beyond the date in question. It does not appear that the services are reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in question.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveinpatient mental health care beyond March 11, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvebone marrow aspiration.You asked the Plan to pre-approvebone marrow aspiration. The Plan denied your request. The Plan says this is considered experimental/investigational.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. Our reviewer says that bone marrow aspiration is not medically reasonable and necessary. Our physician reviewer found that bone marrow aspiration remains experimental for use inspinal fusion surgery. More research is needed.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of bone marrow aspiration have not been met.Therefore, we decided that the Plan does not have to pre-approvebone marrow aspiration.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approveVenofer for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that iron therapy is covered when specific criteria are met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia and stage III chronic kidney disease (not on dialysis). The records do not support that she meets the criteria for coverage of intravenous iron therapy, given that she is not on dialysis. The Venofer is not reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approveVenofer for the enrollee.