Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to waive the coinsurance for the resin composite for 4 or more surfaces (D2374)
for tooth # 14 provided on July 8, 2019.
You asked the Plan to waive the coinsurance for the fillings. You say that the coinsurance should be waived
due to the unusual circumstances of this particular molar. You say that it was a challenge of metal sensitivity
and lack of tooth structure that forced the provider to do what was best. The Plan denied your request. The Plan
says that the claim adjusted appropriately, applying the 20% coinsurance for the silver filling benefit.
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 not substantiated their claim that the total amount
owed by the enrollee was calculated correctly. Therefore, we decided that the Plan has to waive the coinsurance
for the resin composite for 4 or more surfaces (D2374) for tooth # 14 provided on July 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core build up (D2950) and a crown (D2751) for tooth # 5.
You asked the Plan to pre-approve the core build up. You say that tooth # 5 has a broken cusp and is abscessed. The Plan denied your request. The Plan says core build up 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, core build up is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core build up (D2950) and a crown (D2751) for tooth # 5.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 30, 2018 by an out of
network provider.
You asked the Plan to pay for hyperthermia treatment. You say the Dr. authorized the services in
question. 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. No formal referral was submitted to the Plan. 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 30, 2018 by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided  on September 10, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that you feel that the colonoscopy
should be considered preventative. The Plan denied your request. The Plan says the claims were processed
correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $450 copayment for outpatient surgery, including services provided at hospital outpatient facilities
and ambulatory surgical centers.
The record shows that the enrollee received a colonoscopy due to rectal bleeding on September 10, 2019.
Therefore, the colonoscopy is considered diagnostic, not preventative, and the enrollee is responsible to pay the
$450 copayment.
The enrollee has been asked to pay a $450 copayment for a colonoscopy. A colonoscopy falls within the
outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers
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 a colonoscopy provided on September 10, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient psychiatric services rendered to the enrollee from July 17, 2019 to July 23, 2019. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee was voluntarily admitted to the hospital on July 17, 2019 with major depressive disorder, alcohol use disorder, and cocaine use disorder. Based on the submitted records, it was not expected that he would improve in a reasonable period of time, as he was not showing dangerousness to self or others. He had no auditory or visual hallucinations or delusions and was not showing any behavioral issues. He was cooperative and complaint with treatment. It does not appear that active treatment was taking place. The services were not expected to improve his condition or for the purpose of diagnosis. The inpatient psychiatric services were 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 pay for the inpatient psychiatric services rendered the enrollee from July 17, 2019 to July 23, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network physical therapy provider.
You asked the Plan to pre-approve these services. You say that you need to continue physical therapy and your doctor referred you to this provider. The Plan denied your request. The Plan says the services are available from network providers.
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 a referral to an out-of-network physical therapy provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chest x-ray (71046) provided on October 26, 2019.
You asked the Plan to pay for the chest x-ray. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this service was billed with an incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code 71046 is not supported in the record. Specifically, the record indicates that these services were provided in an outpatient/observation setting. The claim has been billed incorrectly with place of service code 21 for inpatient hospital. Based on this information, we decided that Medicare rules for coverage of the chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for a chest x-ray (71046) provided on October 26, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a Contour Next EZ diabetic meter.
You asked the Plan to pre-approve a Contour Next EZ diabetic meter. You say that you are unhappy you have to change from your current diabetic meter. The Plan denied your request. The Plan says that the medical record shows that you have diabetes and need to check your sugars regularly. The plan says that the Contour Next System is not a preferred meter for the Plan. The plan says that there is no medical reason for the enrollee to have this particular meter.
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 not provided any medical records or evidence of having made reasonable attempts to obtain this necessary documentation. Without this information, we are unable to assess whether the continued used of the current meter is medically necessary and appropriate to ensure continuity of care and adequate treatment of the enrollee's medical needs. Despite having made a request to the plan for this necessary documentation, none was provided and the plan has therefore not substantiated their denial. Therefore, we decided that the Plan has to pre-approve a Contour Next EZ diabetic meter. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for CT scan provided on August 31, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you were told that the CT scan
would be covered. 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 $250
copayment for advanced imaging services at an in-network outpatient hospital.
You have been asked to pay a $250 copayment for the CT scan. The CT scan 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 the CT scan provided on August 31, 2019.
Your complaint that the plan is sneaky, slimy, and unreliable 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 pre-approve an office visit (99214) with a tertiary physical medicine
and rehabilitation doctor.
You asked the Plan to pre-approve the office visit. You say that you PCP specifically requested that you see a
tertiary doctor. The Plan denied your request. The Plan says it is not medically
necessary for you to receive care from a highly specialized tertiary center for your condition.
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 office visit. Our reviewer says that
the requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found a non-tertiary physician office visit can address your needs.
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 office visit have not been met. Therefore, we decided that the Plan does not
have to pre-approve an office visit (99214) with a tertiary physical medicine and rehabilitation doctor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 99239 provided on September 24, 2019.
You asked the Plan to pay for CPT code 99239. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
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 99239 is Hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, procedure code 99239 is a time based code. In order to bill CPT 99239, the documentation must note that more than thirty minutes was spent providing services to the enrollee on the day of discharge. The progress note for September 24, 2019 does not note how much time was spent providing services to the enrollee. As such, the provided documentation does not support the billing of CPT 99239. Based on this information, we decided that Medicare rules for coverage of CPT code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 99239 provided on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies rendered to the enrollee from August 13, 2019 to November 1, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says there is no valid proof of delivery.
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS suppliers are required to maintain proof of delivery. We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 pay for the diabetic supplies rendered to the enrollee  from August 13, 2019 to November 1, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Colchicine 0.6 mg capsule medication.
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has a medical (MA) only policy with the plan, not a Prescription Drug Plan (PDP). Therefore, drug coverage is limited to Medicare Part B covered drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Colchicine 0.6 mg capsule medication.
Benefits for the Colchicine 0.06 mg capsule medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Novolog for the enrollee. 
You asked the Plan to pre-approve Novolog. You say that Humalog led to poorer diabetes control. The Plan denied your request. The Plan says Novolog to be taken at home is not covered under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Novolog for the enrollee. 
Benefits for Novolog may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa
You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is more effective than the drugs the plan is requesting the enrollee try. The Plan denied your request. The Plan says the information does not meet the Plan's medical necessity guidelines for coverage. The plan says that the enrollee has not tried Orthovisc or Monovisc prior to this request.
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 Euflexxa. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the provided medical records do no indicate that the enrollee has tried and failed the required drugs. Our physician reviewer found that the provided medical records do not indicate that the Plan's required drugs would likely be less effective 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a pacemaker device evaluation provided on November 7, 2019.
You asked the Plan to waive the copayment for specialist service. You say that you expect to see your doctor and get 1 copayment, not 2 each time. The Plan denied your request. The Plan says the copayment amount 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 $40 copayment for in-network specialist visit. You have been asked to pay $40 copayment for specialist service. Specialist service falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 a pacemaker device evaluation provided on November 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Gel-One 30mg/3ml syringe for the enrollee.
You asked the Plan to pre-approve the syringe. You say that this is medically necessary. The Plan denied your request. The Plan says preferred viscosupplements are Orthovisc and Monovisc and don't require prior authorization.
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 the syringe. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of the required drugs - Orthovisc and Monovisc. The provided medical records do not indicate that the plan's required drugs 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 the syringe have not been met. Therefore, we decided that the Plan does not have to pre-approve a Gel-One 30mg/3ml syringe for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Eylea.
You asked the Plan to pre-approve the Eylea. You say that the documentation provided supports the need for the requested drug. The Plan denied your request. The Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage. The Plan says that the enrollee has not had prior therapy, contraindication to, or intolerance to Bevacizumab.
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 the Eylea. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee has a diagnosis of Tributary (branch) retinal vein occlusion, right eye, with macular edema. The Plan requires a trial of the drug Bevacizumab before they will approve Eylea. The documentation provided does not show that the enrollee has tried and failed this required drug. The documentation provided does not support that Bevacizumab would be less effective or have adverse effects for the enrollee in this case. 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 Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.