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

We decided that the Plan does not have to waive the copayment for the echocardiography provided January 12, 2021.
You asked the Plan to waive the copayment for the diagnostic services. You say that you got an echocardiogram and was expecting the copay of $45 however you were billed $175 and you do not feel this is right. The Plan denied your request. The Plan says the claim was processed with the correct copayment applied per the Evidence of Coverage.
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 $175 copayment for each Medicare covered service for diagnostic imaging (CT scan, MRI/MRA myocardial nuclear perfusion imaging and PET scans).
You have been asked to pay $175 copayment for the diagnostic services. The diagnostic services fall within the Inpatient stay: covered services received in a hospital or SNF during a non-covered inpatient stay 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 echocardiography provided January 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspirate.
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve bone marrow aspirate. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found bone marrow aspirate remains experimental for use in spinal surgery. More research is needed to show safety and efficacy of bone marrow aspirate as a bone graft extender. 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 aspirate have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspirate.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve dialysis to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria have not been met.
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. Therefore, we decided that the Plan does not have to pre-approve dialysis to be provided by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 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 Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the Plan requires a trial of drug zoledronic acid before they will approve the requested drug. In this case, the enrollee has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve direct skilled nursing services from a registered nurse (RN) and services of home health/hospice aide.
You asked the Plan to pre-approve the skilled nursing services from an RN and home health/hospice aide. You say that your son never lived with you. The Plan denied your request. The Plan says you no longer qualify for home health aide services.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 skilled nursing services from an RN and home health/hospice aide. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found skilled nursing services are not required to effectively provide treatment, care, and/or services in order to improve the patient's condition, or to establish/perform a maintenance program to maintain the patient's condition and/or prevent deterioration beyond what was approved by the health plan. The patient has had diabetic education. The patient's needs do not require a skilled professional nurse. The patient's son was to be trained in Flexi Pen insulin administration. There are no complex wounds or other skilled nursing needs. The request for a home health aide is not medically necessary beyond what was approved by the health plan. The documentation does not reveal that the patient is homebound and therefore does not meet home health aide service criteria. The patient is able to receive informal support from son and personal care/homemaking services offered to her. The request for home health aide services is not reasonable and necessary for the treatment of the patient's illness or injury by the skilled professional staff. 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 skilled nursing services from an RN and home health/hospice aide have not been met. Therefore, we decided that the Plan does not have to pre-approve direct skilled nursing services from a registered nurse (RN) and services of home health/hospice aide.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing panel provided on August 27, 2020.
You asked the Plan to pay for the definitive drug testing panel. You say that this is medically necessary testing that should be reimbursed. The Plan denied your request. The Plan says the incorrect POS code was used for this claim.
The Plan must follow Medicare rules. Medicare rules say that labs must report the POS code where the sample was taken. POS 81 is limited to samples taken directly by the independent laboratory. In this case, the documentation does not support this sample was taken by the lab directly. This sample was taken at the ordering physician's office and delivered to the lab the next day. As such, the reported POS code of 81 is not supported. Therefore, we decided that the Plan does not have to pay for the definitive drug testing panel provided on August 27, 2020.
Appeal type: Home 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 provided on March 4, 2021 by an out of network (OON) provider.
You asked the Plan to pay for the evaluation and management service. You say that the provider in this case relies on the the facility staff to verify eligibility and to obtain the proper authorizations. You also say that the services were provided to the enrollee in good faith. The Plan denied your request. The Plan says the provider
in this case is out of network. The Plan says that authorization was not obtained before the service were rendered to the enrollee. The Plan also says that the service provided was not urgent or 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 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 had network providers available who could have provided 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 provided on March 4, 2021 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visits (99213 and 99214) provided on January 10, 2020, through August 14, 2020.
You asked the Plan to pay for the office visits. You say that you would like reconsideration because you were referred to this provider and not aware that they were not in-network with the Plan. The Plan denied your request. The Plan says that you did not obtain prior authorization for out-of-network care.
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has failed to address the member's argument or verify who referred the member to these services. We are unable to determine if the referring provider is in-network with the Plan. It is the burden of the Health Plan to substantiate their denial with evidence. The Plan's denial has not been substantiated Therefore, we decided that the Plan has to pay for the office visits (99213 and 99214) provided on January 10, 2020, through August 14, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda and Diphenhydramine Hcl.
You asked the Plan to pre-approve Keytruda and Diphenhydramine Hcl. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, 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 Keytruda and Diphenhydramine Hcl. Our reviewer says that the medication is medically necessary. Our physician reviewer found Pembrolizumab is FDA approved for metastatic lung cancer with a PD-L1 >1% and no driver mutations, as well as for metastatic urothelial cancer in enrollees not eligible for platinum based therapy, and for 1st line treatment of metastatic squamous cell of the head and neck. This enrollee fits all these criteria based on the findings of his tumor and would be eligible for pembrolizumab for 1st line treatment. The service is reasonable and medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda and Diphenhydramine Hcl have been met. Therefore, we decided that the Plan has to pre-approve Keytruda and Diphenhydramine Hcl.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
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-approve IRF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the enrollee does not require the intensity of services provided at an
IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and
regular physician evaluation. The enrollee's care needs can be met at a lower level of care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the 2D oral or facial photographic image (D0350) provided on February 2, 2021.
You asked the Plan to pay for the dental service. You say that this service should be covered. The Plan denied your request. The Plan says 2D oral or facial photographic image is not listed as a covered service.
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 2D oral or facial photographic image (D0350) provided on February 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and a panoramic radiographic image (D0330) provided on January 28, 2021.
You asked the Plan to pay for a periodic oral evaluation, a teeth cleaning, and a panoramic radiographic image. You say that you were not aware that the provider had opted out of Medicare. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a periodic oral evaluation, a teeth cleaning, and a panoramic radiographic image have not been met. Specifically, services were provided by an Opt Out provider. The Plan does not cover dental services when provided by an Opt Out provider. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), a teeth cleaning (D1110), and a panoramic radiographic image (D0330) provided on January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration (CPT code 94060) provided on October 12, 2020.
You asked the Plan to waive the copayment for the radiological testing. You say that you were told in earlier phone conversations that the Plan would be waiving copayments until the end of the year in 2020. The Plan denied your request. The Plan says they would waive cost shares until September 30, 2020. The Plan states on June 18, 2020, and November 17, 2020, you were also told by the Plan's customer service department that the Plan would waive cost shares from May 11, 2020, through September 30, 2020. The Plan states you did not receive services from a Primary Care Provider on October 12, 2020 so the services you received for radiological services did not qualify for the cost share waiving.
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 you received radiological testing on October 12, 2020. You were asked to pay a $25 copayment for the testing. Your 2020 EOC states that enrollees must pay a $25 copayment for Medicare-covered non-radiological diagnostic services. 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 bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration (CPT code 94060) provided on October 12, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (CPT code 0239U) provided to the enrollee on February 16, 2021.
You asked the Plan to pay for the laboratory services. You say that you do not have direct access or interaction with patients prior to the time of service and are therefore not responsible for obtaining prior authorization before performing the testing. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.
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 had network providers available who could have provided 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 laboratory services (CPT code 0239U) provided to the enrollee on February 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the echocardiography (CPT code 93306) provided on January 25, 2021.
You asked the Plan to waive the copayment for the echocardiography. You say that the doctor did not do anything for you. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC 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 you received an echocardiography (CPT code 93306) provided on January 25,
2021. You were asked to pay a $110 copayment for the service. Your 2021 EOC states that enrollees must pay a $110 copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). 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 echocardiography (CPT code 93306) provided on January 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for services you had with a urologist from September 15, 2020, to December 10, 2020.
You asked the Plan to waive the copayments for the urology services. You say that you were told there was no copayment for these services. The Plan denied your request. The Plan says you were charged these copayments 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 $30 copayment for each visit to a specialist's office.
You have been asked to pay a $30 copayment for the urology services. The urology services fall within the visits to a specialist's office 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 copayments for services you had with a urologist from September 15, 2020, to December 10, 2020.