Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has rheumatoid arthritis and has failed prior treatment with Enbrel and Humira. She has had hyperlipidemia with Xeljanz and prior adverse reaction to methotrexate. She has not tried and failed the Plan's required drugs of Remicade or Inflectra and Simponi Aria. The records do not support that the required drugs would be less effective or contraindicated; therefore, Actemra is not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve Actemra.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a standalone MAZE procedure.
You asked the Plan to pre-approve the requested services. You say that the enrollee has had atrial fibrillation ablation in the past, which failed. The Plan denied your request. The Plan says surgical MAZE procedures are appropriate only when open heart surgery is already planned for another purpose.
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 the requested services. Our physician reviewer found that the enrollee has a history of hyperlipidemia, hypertension, prostatic hypertrophy, moderate mitral regurgitation, and mild-to-moderate tricuspid regurgitation. The enrollee also has mildly reduced LV ejection fraction (45-50%), and incidentally identified but symptomatic atrial fibrillation that is persistent in spite of endocardial ablation, DC cardioversion, and antiarrhythmic medication. A coronary angiography reported no coronary stenosis. In this circumstance a surgical MAZE procedure has not been shown to be more effective than repeat endocardial ablation. It is generally considered appropriate only when open heart surgery is already planned for another purpose. Since there is no heart surgery planned for another purpose, the documentation does not support the medical necessity for a MAZE procedure. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a standalone MAZE procedure.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve the core build up for tooth # 18 and the fixed bridges. We decided
that the Plan does not have to pre-approve the core build up for teeth # 4, 6, and 20.
You asked the Plan to pre-approve the core build up for tooth # 18 and the fixed bridges. The Plan says that the
requested dental services are not medically necessary according to the criteria for adequate mastication.
We decided that the Plan has to pre-approve the core build up for tooth # 18 and the fixed bridges.
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 dental services. Our reviewer says
that the core build up for tooth # 18 and the fixed bridges are medically necessary. The reviewer found that
tooth # 18 would benefit from core build up prior to placement of a retainer crown to provide better strength
and support. The reviewer also found that the fixed bridges replacing teeth # 4 and 19 would restore the
enrollee to good masticatory function. Therefore, we decided that the Plan has to pre-approve the core build up
for tooth # 18 and the fixed bridges.
We also decided that the Plan does not have to pre-approve the core build up for teeth # 4, 6, and 20.
The reviewer also says that the core build up for teeth # 4, 6, and 20 are not medically necessary. Our physician
reviewer found the documentation provided does not show significant breakdown requiring build up for teeth #
4, 6, and 20. The reviewer found that the core build up for teeth # 4, 6, and 20 is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the core build up for teeth # 4, 6, and 20 have not been met. Therefore, we
decided that the Plan does not have to pre-approve the core build up for teeth # 4, 6, and 20.
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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit services provided on January 9, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 rest home visit services provided on January 9, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on December 6, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the submitted documentation did not contain sufficient detail to support the billed charges. The documentation does not include any evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the injection provided on January 13, 2020.
You asked the Plan to waive the copayment for the injection. You say that you have never been charged a copayment for a B-12 injection previously. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for Medicare-covered surgical or other services provided to you at an in-network outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $325 copayment for the injection.
You have been asked to pay a $22.18 copayment for the injection. The injection falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows the injection is considered a physician service.
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 injection provided on January 13, 2020.
Our decision is only about the 2020 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 1, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for office visit. You say that there is no prior authorization requirement for this
service. 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 enrollee self-directed for service.
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 February 1, 2020
by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), vertical bitewings (D0277), and panoramic x-ray (D0330) provided on January 8, 2020 by an OON provider.
You asked the Plan to pay for the comprehensive oral evaluation, vertical bitewings, and panoramic x-ray. You say that you were assured that this provider was fine to use, and you would be covered. The Plan denied your request. The Plan says the total member liability amount was applied correctly. The Plan also says that the enrollee may be billed by the out-of-network provider for any amount greater than the payment made by the Plan to the provider or any services not covered by the Plan.
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 the allowed amount. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), vertical bitewings (D0277), and panoramic x-ray (D0330) provided on January 8, 2020 by an OON provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the endoscopy provided on January 16,
2020.
You asked the Plan to waive the copayment for the endoscopy. You say that both procedures were a screening.
You say that the copayment makes no sense. The Plan denied your request. The Plan says the copayment
applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $275 per
day for outpatient procedures and services, including but not limited to diagnostic and therapeutic endoscopy,
and surgery performed in an outpatient hospital or ambulatory surgical center.
You have been asked to pay a $275 copayment for the endoscopy. The endoscopy falls within the "Outpatient
surgery including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit
category. The endoscopy is considered a surgical procedure. 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 endoscopy provided on January 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe CPAP supplies provided on May 28, 2019.You asked the Plan to waive the coinsurance forthe CPAP supplies. You say that you cannot afford this.The Plan denied your request. The Plan says that you are responsible for the cost-sharing.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-covered durable medical equipment. You have been asked to pay a 20% coinsurance for the CPAP supplies. The CPAP supplies fallwithin the Medicare-covered durable medical equipment benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe CPAP supplies provided on May 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the home automatic blood pressure monitor (A4670).
You asked the Plan to pre-approve the home automatic blood pressure monitor. You say that you just had surgery and is bed bound. You are on a fixed income. Your doctor wants you to check your blood pressure but you do not have this device. The Plan denied your request. The Plan says the requested item is not covered. This item is only covered for patients that are on home dialysis.
The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis, or those who meet the criteria for white coat hypertension and require ABPM to confirm a diagnosis of hypertension. The records do not show that this monitor is requested in the setting of home dialysis services, or that this request is for evaluation of suspected white coat hypertension. Although monitoring blood pressure in the home may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item in this situation. Therefore, we decided that the Plan does not have to pre-approve the home automatic blood pressure monitor (A4670).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for DME provided on December 31, 2019.You asked the Plan to waive the coinsurance for DME. You say that you were told that you would only owe a $40 copayment.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 20% coinsurance for DME and related supplies. You received DME on December 31, 2019. The allowed amount is $435.28 and 20% of that is $87.06. You have been asked to pay the total coinsurance amount of $87.06 for DME. DME falls within the DME and related 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 coinsurance for DME provided on December 31, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on November 22, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for an outpatient surgery. You say that you had success with the surgery. You say
that you do not think that the Plan has your best interests at heart. The Plan denied your request. The Plan says
no prior authorization was obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an outpatient surgery provided on November 22,
2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe emergency room visit provided on February 6, 2020.You asked the Plan to waive the copayment forthe emergency room visit. You say that you do not believe you should be responsible for the copayment. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for each Medicare-covered emergency room visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care/ Post-Stabilization Care" benefit category. The record shows you received services during your emergencyroom visit.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 forthe emergency room visit provided by on February 6, 2020.Your complaint about not received the proper care 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for comprehensive eye exam (92014) and refraction service
(92015) provided October 9, 2019.
You asked the Plan to pay for the vision services. You say that you have a check up with an ophthalmologist
annually because you have had problems with your eyes since birth. You could purchase your glasses. The Plan
denied your request. The Plan says enrollee's must receive their vision services from an in-network provider
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers these services when rendered by network providers..
We looked at the file and the Plan's rules. For covered vision services you must receive vision services from an
in-network provider. Based on this information, we decided that the Plan's rules for coverage of the vision
services have not been met. Therefore, we decided that the Plan does not have to pay for comprehensive eye
exam (92014) and refraction service (92015) provided October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve over-bed table (E0274).You asked the Plan to pre-approveover-bed table. You say that when the supplier brought you your hospital bed they offered to provide the tray but you declined but now you need it so you can eat comfortably.The Plan denied your request. The Plan says this is a convenience item and is therefore not a covered benefit.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-approveover-bed table (E0274).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 95951) provided on November 30, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 95951 is "Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical localization), each 24 hours".We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of CPT code 95951 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation to support that "Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical localization), each 24 hours" was performed on November 30, 2019, therefore this service cannot be verified.We looked at this coder'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 pay for the services (CPT 95951) provided on November 30, 2019.