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

We decided that the Plan does not have to pre-approve Retacrit for the enrollee.

You asked the Plan to pre-approve Retacrit. You say that this drug is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not 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 Retacrit. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found the enrollee has a history of polymyalgia rheumatica and CREST syndrome. The current guidelines show there is evidence of benefits to using ESA therapy to reduce transfusions for selected patients with significant refractory and symptomatic anemia who have inflammatory diseases (rheumatoid arthritis, Crohn's disease, ulcerative colitis), and Hepatitis C with anemia due to the medication regimen. Until further publications show clear benefit, ESAs for anemia of other chronic diseases other than those listed above will not be covered. The review has determined that the documentation does not support that the Retacrit is medically reasonable and necessary for the patient. The documentation does not support that the Retacrit is safe and effective for this 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 Retacrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Retacrit for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology procedure (CPT code 81406) and unlisted molecular pathology procedure (81479).

You asked the Plan to pay for the services. You say that this testing was ordered by the physician with a professional determination of medical necessity and the results of this genetic testing will have a direct impact on this enrollee's treatment and management. The Plan denied your request. The Plan says predictive screening testing is not a Medicare benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered. The test at issue in this appeal, the services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for molecular pathology procedure (CPT code 81406) and unlisted molecular pathology procedure (81479).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI.

You asked the Plan to waive the copayment for an MRI. You say that the facility said that they could not perform more than one MRI a day and you feel that this information is incorrect. 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 $250 copayment for diagnostic radiology services.

You have been asked to pay a $250 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies 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 an MRI.

We note your complaint that the facility told you that they cannot perform more than one MRI a day. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, resin-based composite of one surface, resin-based composite of two surfaces, and resin-based composite of three surfaces provided by an OON provider.

You asked the Plan to pay more for the periodic oral evaluation, prophylaxis, and resin-based composites. You say that you were not aware that this provider is OON. The Plan denied your request. The Plan says the total $386.00 amount applied correctly as member liability. The Plan also says that cost sharing is a contractual obligation under the Plan and cannot be waived.

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, you are responsible for the difference between the billed amount and allowed amount. Therefore, we decided that the Plan does not have to pay more for the periodic oral evaluation, prophylaxis, resin-based composite of one surface, resin-based composite of two surfaces, and resin-based composite of three surfaces provided by an OON provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the hepatechtomy (47120) and nephrectomy (50230) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are in network providers available for these services.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 the hepatechtomy (47120) and nephrectomy (50230) to be provided by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pre-approve a crown for tooth number 30.

You asked the Plan to pre-approve a crown for tooth number 30. You say that this crown is medically necessary. The Plan denied your request. The Plan says that medical necessity has not been established.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a crown for tooth number 30. Our reviewer says that the requested crown is considered medically reasonable and necessary in this case. Our physician reviewer found the dental records provided show the need for a replacement crown (D2740) for tooth number 30 to restore it to adequate function due to recurrent caries and ill-fitting crown. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a crown for tooth number 30 have been met. Therefore, we decided that the Plan has to pre-approve a crown for tooth number 30.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two additional resin-based composites (D2392 x2).

You asked the Plan to pay for the resin-based composites. You say that the frequency denial for these services is inappropriate. The Plan denied your request. The Plan says benefits for this service had been satisfied and the frequency limitations had 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, restorations (fillings) are limited to two procedures per calendar year. The record shows that you received four resin-based composites, two of which were covered by the Plan, and your restorations benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the two additional resin-based composites (D2392 x2).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for foot orthotics.

You asked the Plan to pay for foot orthotics. You say that you would like this claim reprocessed and approved for payment. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for an automatic external defibrillator (AED) garment (Lifevest).

You asked the Plan to pay for Lifevest. You say that you are requesting to extend the timely filing limit and overturn this denial based on overall care provided. The Plan denied your request. The Plan says the denial of payment for this item is correct, because this claim was not submitted within the timely filing limit.

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 Lifevest was not filed. 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 an automatic external defibrillator (AED) garment (Lifevest).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of radiographic images (D0210), the
resin-based composite-two surfaces, anterior (D2331), and the unspecified preventive procedure (D1999).

You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says you have exhausted the benefit for the
complete series of radiographic images and the resin-based composite. Additionally, the unspecified preventive
procedure is not a covered benefit under your dental policy.

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 case file and the Plan's rules. Based on this information, we decided that the Plan's rules for
coverage of these services have not been met. Specifically, the Plan contract covers six fillings per calendar
year and one complete series of radiographic images or panoramic x-ray. The Plan previously issued payment
for six fillings and one complete series of x-rays, less than one calendar year prior. You have exhausted the benefit for these services provided. Additionally, the unspecified preventive procedure provided is not a covered benefit under your dental policy. Therefore, we decided that the Plan does not have to pay for the complete series of radiographic images (D0210), the resin-based composite-two surfaces, anterior (D2331), and the unspecified preventive procedure (D1999).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the three-day inpatient hospital stay provided from August 12, 2020 to August 15, 2020.

You asked the Plan to waive the copayment for the inpatient care. You say that while you were in the hospital, you received a notice that the Plan was going to start offering COVID-19 relief enhanced benefits starting August 17, 2020. If you had known sooner, you would have waited until these benefits took effect. The Plan denied your request. The Plan says the enhanced benefits had not started at the time of the care, and inpatient hospital stays require a $350 copayment for each of the first five days.

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 $350 copayment for each of the first five days of inpatient hospital care. 

You have been asked to pay a $1,050 copayment for three days of inpatient care ($350 x 3 = $1,050). 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 three-day inpatient hospital stay provided from August 12, 2020 to August 15, 2020.

Your complaint about the timing of the benefits notice and whether or not the Plan could make a one-time exception to their COVID-19 relief enhanced benefit policy is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a vaccination provided on October 15, 2020.

You asked the Plan to pay for the vaccination. The Plan denied your request. The Plan says you must receive care from a network provider. In most cases the care you receive from an out-of-network provider will not be covered. 

If you need medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care, you may get this care from an out of network provider. You, or your PCP must obtain authorization from the Plan prior to seeking care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The 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 a vaccination provided on October 15, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on August 6, 2020.

You asked the Plan to waive the copayment for the ambulance services. You say that you were given misinformation from a representative and thus the enrollee should not be responsible for the copayment. The Plan denied your request. The Plan says the copayment 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $195 copayment per one way trip for Medicare-covered ground ambulance services. The enrollee has been asked to pay a $195 copayment for ambulance services. 

This service falls within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance services provided on August 6, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the home drug infusion services (S9379)
provided from May 2, 2020, to May 8, 2020.
You asked the Plan to waive the coinsurance for the home infusion services. You say that you should not be
responsible for these treatments because a dose was missed due to issues with the infusion pump. The Plan
denied your request. The Plan says Medicare Part B drugs require 20% coinsurance. The Plan also states that
they reached out to the provider, who was unable to provide additional information.
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 for Medicare Part B prescription drugs.
You have been asked to pay $80.64 for the home infusion services The Plan's total allowed amount for the 7
days of this service is $403.13 ($403.13 x 20% = $80.64). Home infusion services 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 for the home drug
infusion services (S9379) provided from May 2, 2020, to May 8, 2020.
Maximus Federal Services read your letter and knows that you may have a quality-of-care concern. Maximus
Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the
appropriate Quality Improvement Organization for further review.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing this denial. 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 authorization was not 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 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 medical services provided on August 4, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 22, 2020, by an
OON provider.
You asked the Plan to pay for physician visit. You say that this service was medically necessary. 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 authorization was not 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 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 medical services provided on October 22,
2020, by an OON provider.
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 IRF admission is medically necessary. The Plan denied your request. The Plan says your needs can be met at a different level of care.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found based on the medical records provided the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You may require skilled physical therapy and occupational therapy but based on the medical records provided It is not clear you would be able to fully benefit and/or participate in an IRF 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.