Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visit you had with a neurologist on March 25, 2021.

You asked the Plan to waive the copayment for the neurology visit. You say that this visit was requested by the physician. You said that you had facial swelling, so your doctor wanted to follow-up with you. The Plan denied your request. The Plan says you were charged this copayment 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 $20 copayment for specialist visits. 

You have been asked to pay a $20 copayment for the neurology visit. The neurology visit falls within the specialist visits benefit category. This copayment applies regardless of the reason for the 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 for the visit you had with a neurologist on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to provide additional payment for the frames (V2020) and progressive lens, per lens (V2781) provided February 17, 2021.
You asked the Plan to provide additional payment for the frames and progressive lenses. You say that you were told your frames and lenses would be covered with 20% coinsurance. The Plan denied your request. The Plan says the frames have been covered with 20% coinsurance however the lens upgrades are not covered.
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 one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery with 20% coinsurance when provided out of network. We looked at the file and the Plan's rules. The Plan provided documentation showing that the frames have been covered with 20% coinsurance. The progressive lenses are an upgrade and therefore are not covered. Therefore, we decided that the Plan does not have to provide additional payment for the frames (V2020) and progressive lens, per lens (V2781) provided February 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on March 27, 2021, to April 1, 2021.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you were told that you would have a $0 copayment. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $385 copayment per day, for days 1-5 for inpatient hospital care. Your contract with the Plan also clearly says that you pay a $0 copayment for days 6 and beyond for inpatient hospital care.

You have been asked to pay a $385 copayment per day, for days 1-5 for inpatient hospital care. The records show that you were admitted for an inpatient hospital stay from March 27, 2021, to April 1, 2021. The EOC confirms $385 per day is the required copayment for this service. Your total cost-share is $1,925 ($385 x 5 days = $1,925). 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 inpatient hospital care provided on March 27, 2021, to April 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bevacizumab (J9035) and Atezolizumab (J9022).
You asked the Plan to pre-approve Bevacizumab and Atezolizumab. You say that you need both of these drugs. The Plan denied your request. The Plan says maintenance Bevacizumab and Atezolizumab after completing definitive chemotherapy radiation is not an endorsed standard of care regimen.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Bevacizumab and Atezolizumab. Our reviewer says that Bevacizumab (J9035) and Atezolizumab (J9022) are not medically reasonable and necessary. Our physician reviewer found the requested use of Bevacizumab (J9035) and Atezolizumab (J9022) is not FDA-approved for the enrollee's diagnosis. Our reviewer found that the use of these drugs is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. Our physician reviewer also found that the use is not listed as not indicated, not supported or not recommended in any of the compendia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Bevacizumab and Atezolizumab have not been met. Therefore, we decided that the Plan does not have to pre-approve Bevacizumab (J9035) and Atezolizumab (J9022).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from February 8, 
2021, through March 1, 2021. 
 
You asked the Plan to waive the copayment for physical therapy. You say that the physical therapy bill should 
be checked. The Plan denied your request. The Plan says the copayments applied correctly and the provider has 
been advised that they are responsible for submitting this information to Medicaid. 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 
copayment for physical therapy with an in-network provider.  
 
You have been asked to pay a $20 copayment for each physical therapy visit. The total amount owed is $160 
($20/visit x 8 visits =$160). Physical therapy falls within the "Outpatient rehabilitation services" 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 physical therapy provided from February 8, 
2021, through March 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for imaging of the eye using a special microscope (92286) provided on November 10, 2020.

You asked the Plan to waive the copayment for an outpatient diagnostic test. You say that you had a routine eye exam and should not have a diagnostic test copayment applied. The Plan denied your request. The Plan says the copayment you are being charged is correct.

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 $50 copayment for outpatient diagnostic tests and therapeutic services and supplies.

You have been asked to pay a $45.80 copayment for an outpatient diagnostic test. The EOC confirms that $50 is the required copayment for this service. You have been asked to pay a copayment of $45.80, which is less than the Plan's contracted amount. The Plan contract says that if you receive services in addition to outpatient diagnostic tests, a separate cost-share may apply. 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 imaging of the eye using a special microscope (92286) provided on November 10, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee has no daily skilled nursing needs and does not require daily skilled therapy services on an inpatient basis in an SNF. 

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 care have not been met. Specifically, medically necessary services can be obtained at a lower level of care. This means SNF care is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an MRI provided on September 26, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for an MRI. You say that you would like this reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained for these services. The Plan says that the member's primary care physician did not refer 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 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 an MRI provided on September 26, 2020 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.

You asked the Plan to pre-approve Synvisc-One. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.

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 Synvisc-One. Our reviewer says that Synvisc-One is not approved, as step criteria have not been met. Our physician reviewer found you have not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the Plan, requires that these be trialed first. Our reviewer also found that the documentation does not outline contraindications or reasons these medications were not considered. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a colonoscopy (45378) provided on April 5, 2021.
You asked the Plan to waive the coinsurance for a colonoscopy. You say that you were under the assumption that the colonoscopy would be covered with no cost share, as your doctor suggested you have it done. The Plan denied your request. The Plan says the copayment you are being charged is correct.
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 outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.
You have been asked to pay a 20% coinsurance for a colonoscopy. The allowed amount of the claim is $792.70, resulting in a coinsurance obligation of $158.54. The EOC confirms 20% is the required coinsurance for this service. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a colonoscopy (45378) provided on April 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve facet joint injections.
You asked the Plan to pre-approve facet joint injections. You say that you are going to get worse and want to be able to get out of bed. You say that you are in a lot of pain. The Plan denied your request. The Plan says the criteria for coverage of facet joint injections 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 facet joint injections. Our reviewer says that the requested facet joint injections are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has radiculopathy. The records do not show that the enrollee's radiculopathy is caused by a facet joint synovial cyst.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of facet joint injections have not been met. Therefore, we decided that the Plan does not have to pre-approve facet joint injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the glasses fitting provided on March 23, 2021.
You asked the Plan to pay for the glasses fitting. You say that the patient did not have any input in choosing which optometrist would treat him. You say that a provider performing services in a nursing facility is not responsible to obtain authorization and the service should be reimbursed. The Plan denied your request. The Plan says eyeglasses are not a Medicare covered benefit.
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 contract does not list glasses fittings as a covered benefit. We looked at the file and the Plan's rules. Glasses fittings are not listed as a covered benefit. Based on this information, we decided that the Plan's rules for coverage of the glasses fitting have not been met. Therefore, we decided that the Plan does not have to pay for the glasses fitting provided on March 23, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Enhanced External Counterpulsation (ECP) therapy and treatment with an out-of-network (OON) provider at the in-network benefit level.

You asked the Plan to pre-approve the OON treatment at the in-network benefit level. You say that there are no in-network providers who can provide the medically necessary treatment being requested. The Plan denied your request. The Plan says that the enrollee has a PPO plan which allows for coverage with out-of-network (OON) providers. The Plan says that, because of this, the enrollee can see an OON provider but must pay the applicable OON cost-sharing.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The rules say that the Plan must arrange for specialty care outside of the plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical needs. 

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 not provided us with names of specific in-network providers who are able to supply Enhanced External Counterpulsation (ECP) therapy. This means that the Plan must arrange for the specialty care at the in-network cost-sharing level, since their network has not been shown to be adequate for the enrollee's needs. Therefore, we decided that the Plan has to pre-approve Enhanced External Counterpulsation (ECP) therapy and treatment with an out-of-network (OON) provider at the in-network benefit level.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve therapeutic facet joint injection procedure.
You asked the Plan to pre-approve therapeutic facet joint injection procedure. You say that this service is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the requested procedure have not been met.
The Plan must follow Medicare rules. Medicare rules say that the enrollee is required to have had two (2) medically reasonable and necessary diagnostic facet joint procedures with each one providing a consistent minimum of 80% relief of primary (index) pain. We looked at the file and Medicare rules. In this case, the medical records provided do not document the amount of pain relief that the enrollee received after their second diagnostic facet joint procedure. Based on this information, we decided that Medicare rules for coverage of therapeutic facet joint injection procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve therapeutic facet joint injection procedure.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray of the femur (73552), x-ray of the knee (73560) and x-ray of the tibia and fibula (73590) provided on February 17, 2021.

You asked the Plan to pay for the x-rays. You say that you would like reconsideration because this provider has been credentialed by Medicare Part B to bill globally. The Plan denied your request. The Plan says these codes have not been billed with an appropriate modifier.

The Plan must follow Medicare rules. Medicare rules say that for services that contain both a technical component and a professional component, the technical component, if any, must be billed by the Skilled Nursing Facility (SNF) for its Part A inpatients. The A/B MAC (B) will pay only the professional component to the physician.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the x-rays have not been met. Specifically, the Plan has confirmed that the member was in a Part A covered SNF stay on the billed date of service. In this instance, it is not appropriate to bill these services globally. The SNF must bill the technical component of these services. Payment for the technical component is the responsibility of the facility to any vendor. Therefore, we decided that the Plan does not have to pay for the x-ray of the femur (73552), x-ray of the knee (73560) and x-ray of the tibia and fibula (73590) provided on February 17, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (D0220), crown (D2750),
and core buildup, including any pins when required (D2950) provided on March 25, 2021.

You asked the Plan to pay for the first intraoral periapical x-ray, crown, and core buildup. You say that you
thought you were on the same plan as last year, but when you called the agent you spoke with advised that you
are not. You also say that you cannot afford to pay this bill. The Plan denied your request. The Plan says these
services are not covered.

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 first
intraoral periapical x-ray (D0220), crown (D2750), and core buildup, including any pins when required
(D2950) provided on March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services you received from March 24, 2020, to March 28, 2020.

You asked the Plan to waive the copayment for the inpatient hospital services. You say that you cannot afford this bill and you were not happy with the care you received. The Plan denied your request. The Plan says you were charged this copayment 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 $393 copayment per day for days 1-5 for inpatient hospital care. 

Records show that you were in the hospital for three days. You have been asked to pay a copayment of $393 per day for a total of $1179.00. 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 inpatient hospital services you received from March 24, 2020, to March 28, 2020.