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

We decided that the Plan does not have to waive the coinsurance for the chemotherapy drugs you received from November 10, 2020, to January 5, 2021.
You asked the Plan to waive the coinsurance for the chemotherapy drugs. You say that you cannot afford this coinsurance The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for chemotherapy drugs. You have been asked to pay 20% coinsurance for the chemotherapy drugs. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the coinsurance for the chemotherapy drugs you received from November 10, 2020, to January 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment and the implant supported porcelain/ceramic crown provided on March 3, 2021.
You asked the Plan to pay for these services. You say that you would like this claim to be paid. The Plan denied your request. The Plan says that these services are 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, 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 custom fabricated abutment and the implant supported porcelain/ceramic crown provided on March 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on January 23, 2020, by an out-of-network provider.
You asked the Plan to waive the coinsurance for the evaluation and x-rays. You say that you were told you were covered for up to $1,000 a year. You feel the Plan should pay the full bill because you had not met your annual maximum yet. The Plan denied your request. The Plan says while the Plan does cover a maximum of $1,000 for supplemental dental services each year, you are also responsible for 50% of the billed charges for out-of-network services up to this allowance.
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 50%
coinsurance for preventative and comprehensive dental services received out-of-network. You have been asked to pay 50% coinsurance for the evaluation and x-rays. The evaluation and x-rays fall within the preventative and comprehensive dental services benefit category, and in this case were provided out-of-network. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the comprehensive oral evaluation (D0150) and complete series of intraoral x-rays (D0210) provided on January 23, 2020, by an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital services you received from January 9, 2021, to January 13, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you were not in the hospital by choice. You also say that you cannot afford this copayment. 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 $360 copayment per day for days 1-5 for inpatient hospital services. You have been asked to pay a $360 copayment per day for the inpatient hospital services. There is no provision in your contract for a waiver of this copayment for any reason. 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 inpatient hospital services you received from January 9, 2021, to January 13, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the automatic external defibrillator you received on January 15, 2021.
You asked the Plan to waive the coinsurance for the automatic external defibrillator. You say that you were advised shortly after you received this item that you no longer needed it. You were told to return the item at your convenience. You do not think you should have to pay this coinsurance. The Plan denied your request. The Plan says you were charged this item correctly. Records show that you did not contact the equipment company to return the item until February 5, 2021.
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 durable medical equipment.
You have been asked to pay 20% coinsurance for the automatic external defibrillator. The automatic external defibrillator falls within the 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 for the automatic external defibrillator you received on January 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Romosozumab injections you received from February 11, 2021, to March 11, 2021.
You asked the Plan to waive the coinsurance for the Romosozumab injections. You say that when you had these injections in the past with no copayment, so you don't know why you are getting charged now. The Plan denied your request. The Plan says this coinsurance was charged correctly. The Plan also noted that the hospital did not actually bill for this drug in November, December, and January, which is why you did not have coinsurance charged for those.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B drugs.
You have been asked to pay 20% coinsurance for the Romosozumab injections. The Romosozumab injections fall within the Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Romosozumab injections you received from February 11, 2021, to March 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided out of network on January 13, 2021.
You asked the Plan to pay for out of network vision services. You say that these vision services should be covered by the Plan. The Plan denied your request. The Plan says based on the phone log review; you were given previous notice that out of network vision services were 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 only covers vision services when provided. Therefore, we decided that the Plan does not have to pay for vision services provided out of network on January 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the spine you had on March 10, 2021.
You asked the Plan to waive the copayment for the MRI. You say that you shouldn't have to pay a copayment because this was a yearly follow-up. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this MRI ($167.67) is less than your copayment obligation, you are responsible for the full allowed 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 $225 copayment for advanced imaging services. You have been asked to pay a $225 copayment for the MRI. The MRI falls within the advanced imaging
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 the magnetic resonance imaging (MRI) of the spine you had on March 10, 2021.
Appeal type: Outpatient Therapies
Decision: Favorable

We decided that the Plan has to pre-approve stereotactic radiation therapy for the enrollee.

You asked the Plan to pre-approve the therapy. You say that this is medically necessary. The Plan denied your request. The Plan says that there are not enough studies on the efficacy of radiation therapy to treat plantar fasciitis.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the therapy. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the use of radiotherapy to treat plantar fasciitis dates back many decades and is commonly practiced in Germany and other European countries. While radiotherapy is not commonly utilized for plantar fasciitis in the US, it is an effective treatment for which many US doctors (who would refer for radiation) are unfamiliar. However, it is an accepted standard for plantar fasciitis that is resistant to less invasive therapies. Radiation for treatment-resistant plantar fasciitis, based upon published literature and guideline statements (from Germany) would be considered to be furnished with accordance of accepted standards of care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy have been met. Therefore, we decided that the Plan has to pre-approve stereotactic radiation therapy for the enrollee.

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81286, 81404, 81407, 81408) provided on December 21, 2020.

You asked the Plan to pay for a comprehensive cardiovascular genetic panel. You say that this was medically necessary. The Plan denied your request. The Plan says this is not covered.

The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic (with signs and symptoms) patients with suspected or documented CV disease because panel testing is not specific to a given patient's lipid abnormality or disease. 

We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered. Based on this information, we decided that Medicare rules for coverage of a comprehensive cardiovascular genetic panel have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive cardiovascular genetic panel (81286, 81404, 81407, 81408) provided on December 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an ophthalmology consultation to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve an ophthalmology consultation. You say that the enrollee did not realize a contact lens needed to be removed from his eye following glaucoma surgery and is currently out of the area. The Plan denied your request. The Plan says the requested services are available within the network and you do not meet exception criteria to have the services covered OON.

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 requested care is not urgent or emergent. 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 an ophthalmology consultation to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural injection for the enrollee.

You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says there are no nerve-related deficits on exam.

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 injection. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review indicates that the enrollee has bilateral knee pain and low back pain. On exam she has some decreased range of motion with bending and extending of the back. She has normal muscle strength and a normal neurological exam. She has been treated with medication, chiropractic care, and massage therapy without appropriate pain relief. Her pain management provider stated the the enrollee's current main complaint is bilateral knee pain. There is no specific clinical rationale for the requested lumbar epidural steroid injection. The enrollee does not meet the criteria for this request.

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural injection for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on January 24, 2021.

You asked the Plan to waive the copayment for the ambulance transport. You say that the bill was incurred because you were being transported to receive COVID treatment. 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 a $250 copayment for each one-way Medicare-covered trip.

You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 the ambulance transport provided on January 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the botulinum toxin (Botox) injection you received on February 16, 2021.
You asked the Plan to waive the coinsurance for the Botox injection. You say that you have received this service for over twenty years and have never had to pay anything. The Plan denied your request. The Plan says your benefits changed in 2021 and you now have coinsurance for Part B drugs. The Plan says that you were charged this coinsurance correctly.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan contract says that enrollees must pay 20% coinsurance for Part B covered drugs. You have been asked to pay 20% coinsurance for the Botox injection. The Botox injection falls within the Part B covered drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the botulinum toxin (Botox) injection you received on February 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and core buildup, including any pins (D2950) provided February 17, 2021.
You asked the Plan to pay for the crown and core buildup. You say that you asked to have the same benefits as your previous plan and expected the services to be covered. The Plan denied your request. The Plan says these services are not covered under your dental 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, 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 crown - porcelain/ceramic (D2740) and core buildup, including any pins (D2950) provided February 17, 2021.
Your complaint about potentially being provided misinformation when you signed up for the Plan 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 waive the copayment for the eye drug injection provided on June 11,
2020, September 10, 2020, and December 10, 2020.
You asked the Plan to waive the copayment for the eye drug injection. You say that this is an injection of a
class B drug in an office setting not outpatient surgery. The Plan denied your request. The Plan says the
copayments 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 a $450
copayment per visit for outpatient surgery.
You have been asked to pay $304.97, which is less than the standard $450 copayment for each eye drug
injection. The total amount you owe is $914.91 ($304.97/injection x 3 injections = $914.91). The eye drug
injection falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and
ambulatory surgical centers" benefit category. The eye drug injection is considered a separate surgical service
from the Part B drugs that were administered.
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 eye drug injection provided on June 11, 2020,
September 10, 2020, and December 10, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on December 18, 2020.

You asked the Plan to pay for the laboratory services. You say that you disagree with the plan's denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 the laboratory services are not supported in the medical record. Specifically, if a laboratory assays two or more genes in an enrollee in parallel, then those two or more genes will be considered part of the same panel. A panel constitutes a single procedural service, so one code must be submitted for the panel. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on December 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7321), 20 mg/2 ml syringe.

You asked the Plan to pre-approve Euflexxa injections. You say that requested drug is medically necessary. The Plan denied your request. The Plan says there is no evidence that the enrollee has tried and failed physical therapy. The Plan says there is no radiographic evidence of osteoarthritis. The Plan also says that the requested drug does not meet the criteria for coverage.

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 Euflexxa injections. Our reviewer says that Euflexxa is not medically necessary. Our physician reviewer found the provided documentation does not show evidence of osteoarthritis. The reviewer found that the documentation does not support that the Euflexxa is medically reasonable and necessary for the enrollee. The reviewer also found that the documentation does not support that the Euflexxa is safe and effective 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7321), 20 mg/2 ml syringe.