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

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve the Synvisc-One. You say that the Synvisc-One is medically necessary. The
Plan denied your request. The Plan says a trial of both Orthovisc and Monovisc is required before alternatives
can be considered.
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 Synvisc-One. Our reviewer says
that the rules for coverage of Synvisc-One have not been met. Our physician reviewer found there was no
record of a trial of both plan preferred drugs, and the record does not show any reason why the plan preferred
drugs would be contraindicated 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 the Synvisc-One have not been met. Therefore, we decided that the Plan does
not have to pre-approve Synvisc-One (J7325).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation, panoramic xray,
and two extractions provided on February 6, 2020 by an OON provider.
You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, and extractions.
You say that this provider and his address are listed in the Plan's Provider and Pharmacy Directory as a current
provider within the Plan's network. The Plan denied your request. The Plan says these services were rendered
by an OON provider. The Plan also says that no benefits are available for procedures performed by OON
providers.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the problem
focused limited oral evaluation, panoramic x-ray, and two extractions provided on February 6, 2020 by an
OON provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 9, 2020. 
 
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 screening tests are not covered. 
 
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 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 the laboratory services rendered on January 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fulvestrant (J9395), Ondansetron Hcl per 1mg (J2405), Dexamethasone sodium phosphate 1mg (J1100), and Diphenhydramine hcl up to 50mg (J1200).
You asked the Plan to pre-approve Fulvestrant, Ondansetron Hcl, Dexamethasone sodium phosphate, and Diphenhydramine hcl. You say that the medications are necessary. The Plan denied your request. The Plan says they are not responsible for covered routine costs associated with clinical trials.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Fulvestrant, Ondansetron Hcl, Dexamethasone sodium phosphate, and Diphenhydramine hcl as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Fulvestrant
(J9395), Ondansetron Hcl per 1mg (J2405), Dexamethasone sodium phosphate 1mg (J1100), and Diphenhydramine hcl up to 50mg (J1200).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for tint, photochromatic lens (V2744) provided October 25,
2019.
You asked the Plan to pay for the vision services. You say that you recently had eyelid and cataract surgery and
now your eyes are extremely light sensitive. The Plan denied your request. The Plan says this service is not
covered under the plan benefits.
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 says that upgrades are not covered .
We looked at the file and the Plan's rules. Upgrades are not covered (including, but not limited to, deluxe
frames, tinting, progressive lenses or antireflective coating. 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 tint, photochromatic lens (V2744) provided October 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on December 30, 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 screening tests are not covered.
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 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 the laboratory
services rendered on December 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Spiriva respimat 2.5mcg inh (J3535).
You asked the Plan to pre-approve Spiriva respimat 2.5mcg inh. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Spiriva respimat 2.5mcg inh (J3535).
Benefits for Spiriva respimat 2.5mcg inh 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 a lumbar epidural injection (62323).
You asked the Plan to pre-approve a lumbar epidural injection. You say that the service is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that coverage for LESIs will be denied if one or more contraindications are present. 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 lumbar epidural injection. Our reviewer says that the service is not medically necessary. Our physician reviewer found the epidural steroid injection (ESI) request does not meet the coverage criteria. The requested services are not medically necessary. It is not reasonable or medically necessary for the enrollee to have the LESI. 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 lumbar epidural injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection (62323).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from January 9, 2020 to January 10, 2020.
You asked the Plan to waive the copayment for the emergency room visit. You say that you would like the copayment waived because you went back the emergency room as a continuation of the procedure with your heart. 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 $75 copayment per emergency department visit. You have been asked to pay a $75 copayment for the emergency room visit. The emergency room visit falls within the "Emergency and Urgent Care 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 the emergency room visit provided from January 9, 2020 to January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 7, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan.
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 physician's services provided on January 7, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for an injection, Magnetic Resonance Imaging (MRI), esophagogastroduodenoscopy (EGD), gastroenterology office visit, and podiatry office visits provided from October 8, 2019 to November 14, 2019.
You asked the Plan to waive the cost-sharing for injection, MRI, EGD, and office visits. You say that you were told that you met your maximum out-of-pocket amount on October 5, 2019, and that all claims past this date would be reprocessed to reflect no further out-of-pocket expense for you. The Plan denied your request. The Plan says the cost-sharing amounts you are being charged are 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 20% coinsurance for injection, $180 copayment for MRI, $200 copayment for EGD, and $40 for each specialist office visit. At the time these claims were processed, $4,282.56 of the $5,000 maximum out-of-pocket amount had been met. Your total cost-sharing responsibility is therefore $717.44, because this amount meets the $5,000 maximum out-of-pocket amount for 2019. You have been asked to pay 20% coinsurance for injection, $180 copayment for MRI, $200 copayment for EGD, and $40 for each office visit. Injection, MRI, EGD, and office visits fall within the "Medicare Part B Prescription Drugs", "Outpatient Diagnostic Tests and Therapeutic Services and Supplies", "Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers", "Physician/Practitioner Services, Including Doctor's Office Visits", and "Podiatry Services" benefit categories. 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 cost-sharing for an injection, Magnetic Resonance Imaging (MRI), esophagogastroduodenoscopy (EGD), gastroenterology office visit, and podiatry office visits provided from October 8, 2019 to November 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the reline of complete maxillary denture (D5730) provided on February 15, 2020. 
 
You asked the Plan to pay for the reline of complete maxillary denture. You say that you were under the impression that the services would be covered by the Plan. The Plan denied your request. The Plan says you have exceeded your maximum benefit. 
 
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 Plan offers a $1,000 annual dental benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are responsible for the full charges of any additional dental services. The record shows that you met the annual maximum benefit on February 15, 2020 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the reline of complete maxillary denture (D5730) provided on February 15, 2020.
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 you are appealing. The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.
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 you do not require the intensity of services provided at an IRF. Specifically, you are not shown to be able to perform 15 hours per week of rehabilitative services with regular physician evaluation. Your care needs can be met at a lower level of care such as skilled nursing facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Sandostatin Lar Depot (J2353). 
 
You asked the Plan to pre-approve Sandostatin Lar Depot. You say that the requested medication is necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Sandostatin Lar Depot. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the review has determined that the documentation does not support that the requested Sandostatin Lar Depot is medically reasonable or necessary for this enrollee. The documentation does not support that the requested Sandostatin Lar Depot is safe or 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 Sandostatin Lar Depot have not been met. Therefore, we decided that the Plan does not have to pre-approve Sandostatin Lar Depot (J2353).
Appeal type: Drugs
Decision: Unfavorable

We decided that The Plan does not have to pre-approve Latuda 40mg Tablets.
You asked The Plan to pre-approve Latuda. You say that the enrollee's condition is improving with this medication. The Plan denied your request. The Plan says the requested drug cannot be covered under the Part B Medical 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 Latuda 40mg Tablets.
Benefits for Latuda may be available under Medicare Part D. Contact the health plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for panoramic radiographic image (D0330) and consultation -
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided
on January 9, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you are appealing for reconsideration of the
denied charges. The Plan denied your request. The Plan says the services are not a covered benefit under the
plan.
Medicare generally does not cover dental services. The Plan follows the same rule.
The dental procedure codes are denied because you do not have supplemental dental coverage under your Plan.
Your Plan includes coverage for Medicare-covered dental services only. The services you are asking the Plan
to pay for involve the care, treatment, filling, removal or replacement of your teeth or the structures directly
supporting your teeth. These are dental services that are not covered or paid for by Medicare. Therefore, we
decided that the Plan does not have to pay for panoramic radiographic image (D0330) and consultation -
diagnostic service provided by dentist or physician other than requesting dentist or physician (D9310) provided
on January 9, 2020 by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered from August 1, 2019 to December 4, 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 are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered from August 1, 2019 to December 4, 2019.
Benefits for these services 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says the care required can be provided in the current inpatient hospital setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on January 7, 2020.
You asked the Plan to pay for the outpatient hospital services. You say that you would like reconsideration
because the services rendered were medically necessary. The Plan denied your request. The Plan says the
provider is ineligible with no Medicare ID on file.
The Plan must follow Medicare rules. Medicare rules say that Substance Abuse Facilities are not eligible to
enroll in Medicare.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the outpatient hospital services have not been met. Specifically, this facility is a Substance Abuse
Facility and is not eligible to enroll in Medicare. Therefore, we decided that the Plan does not have to pay for
outpatient hospital services provided on January 7, 2020.