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

We decided that the Plan does not have to waive the copayment for a medical eye exam and refractions provided October 5, 2020.
You asked the Plan to waive the copayment for the medical eye exam and refractions. You say that the copayment should be waived for the medical eye exam and the refractions should be covered. The Plan denied your request. The Plan says the correct copayment was applied for the medical eye exam. The refractions are not covered.
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 Specialist Visits. Refractions are not a covered benefit. You have been asked to pay a $50 copayment for the medical eye exam and $25 for the refractions. The medical exam is considered a specialist visit. Refractions are not covered. 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 medical eye exam and refractions provided October 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair provided on September 11, 2020.
You asked the Plan to pre-approve a shower chair. You say that this will reduce your risk from falls in the shower. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair provided on September 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on December 11, 2020.
You asked the Plan to waive the copayment for a specialist office visit. You say that you had to get a Covid test prior to a procedure. You say that you do not feel like you should have to pay for this. The Plan denied your request. The Plan says the correct copayment has been applied.
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 $30 copayment for physician/practitioner services/in-network/specialist. You have been asked to pay $22.54 which is less than your copayment amount of $30 for a specialist office visit. Since an office visit took place, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/in-network/specialist 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 specialist office visit provided by a participating provider on December 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 6, 2020.
You asked the Plan to pay for the dental service. You say that the people and the insurance people need to talk to each other. You say that you do not know the difference between certain services. You say that when you use the up the limit on a service, they should know that. The Plan denied your request. The Plan says 1 limtied oral evaluation is covered every plan year. The Plan also says that the frequency limit has been exceeded.
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 frequency limit of 1 limited oral evaluation per plan year has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on September 11, 2020. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on November 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on August 13, 2020.
You asked the Plan to pay for the dental services. You say that you are in network with the enrollee's plan. The Plan denied your request. The Plan says you were not a network provider on the date of service in this case. The Plan says that dental services provided out of network 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, dental services provided out of network are not covered. The record shows that you were not a network provider with the Plan until October 2, 2020. Therefore, we decided that the Plan does not have to pay for the oral exam (D0120) and prophylaxis (D1110) provided on August 13, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visits provided on September 13, 2020, September 17, 2020 and September 24, 2020.
You asked the Plan to waive the copayment for the ER visits. You say that you were advised to return three times for the rest of the treatment. You say that you shouldn't be responsible for the ER copayments for the following visits. 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 $120 copayment for emergency care. You have been asked to pay a $120 copayment for each ER visits. The total amount you owe is $360 ($120/visit x 3 visits = $360). The ER visits falls within the "Emergency care" benefit category. There is no provision in the contract which indicates a copayment would be waived for a service performed as a follow-up. 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 ER visits provided on September 13, 2020, September 17, 2020 and September 24, 2020.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services (90834) provided on September 1, 2020.
You asked the Plan to pay for the outpatient mental health services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 outpatient mental health services (90834) provided on September 1, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve methotrexate tablets.
You asked the Plan to pre-approve self-administered drug. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 methotrexate tablets.
Benefits for self-administered drug 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 trigger point injections (20553, 64400, 64405, 64450).
You asked the Plan to pre-approve trigger point injections. You say that you need this treatment for your migraines. The Plan denied your request. The Plan says this treatment is not supported.
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 trigger point injections. Our reviewer says that trigger point injections are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested approach is considered experimental/investigational and is the subject of on-going clinical trials. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of trigger point injections have not been met. Therefore, we decided that the Plan does not have to pre-approve trigger point injections (20553, 64400, 64405, 64450).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services (97039) to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the physical therapy services. You say that the requested provider is nearby to your employer. The Plan denied your request. The Plan says there are network providers available.

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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services (97039) to be provided by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an acute inpatient hospital admission for lumbar
laminectomy.
You asked the Plan to pay for acute inpatient hospital care. You say that surgery is scheduled for early next
month and that they would like to prevent a delay. The Plan denied your request. The Plan says there is no
documentation provided to support the expectation that the enrollee will require a greater than 2 midnight stay.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our
physician reviewer found the enrollee was authorized to undergo 2 level L3-L5 lumbar laminectomy utilizing
CPT codes 63047 and 63048. These 2 procedures are not found on the CMS Inpatient Only list. There was no
detailed discussion of the listed comorbidities/prior history and/or otherwise complex situations that would
suggest that the enrollee requires a 2-day inpatient stay. The procedure is currently approved as an ambulatory
procedure. Potential for post-op observation and/or inpatient admission has not been precluded, depending on
clinical circumstances post-op. Consistent with Medicare benefit policy manual; chapter 16-general exclusions
from coverage, the 2-day inpatient stay is not medically necessary or reasonable.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the
Plan does not have to pay for an acute inpatient hospital admission for lumbar laminectomy.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zemaira for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the request does not meet the step therapy criteria.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, the enrollee has not tried and failed Prolastin-C. Based on the medical records provided there is no indication that the plan's required drugs would likely be less effective and/or likely have adverse effects. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Zemaira for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit (99201).

You asked the Plan to pay for the chiropractic office visit. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is not a covered service under Medicare.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.

The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit (99201).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9328) provided February 18, 2020
to August 18, 2020.
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the CPT code billed is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code S9328 is not supported in the medical record. Specifically, per the National Physician
Fee Schedule, this CPT code has a status of "I" which means it is invalid for Medicare purposes. Based on this
information, we decided that Medicare rules for coverage of the home infusion services have not been met.
Therefore, we decided that the Plan does not have to pay for home infusion services (S9328) provided February
18, 2020 to August 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services (99213) provided November 17, 2020.
You asked the Plan to pay for the dermatology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim did not include a valid primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 99213 is not supported in the medical record. Specifically, the primary diagnosis listed on the claim (B95.61) is a secondary only diagnosis and cannot be listed as a primary, first listed, or principle diagnosis. Based on this information, we decided that Medicare rules for coverage of the dermatology services have not been met. Therefore, we decided that the Plan does not have to pay for dermatology services (99213) provided November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit.
You asked the Plan to waive the copayment for the specialist office visit. You say that you needed to have your ears checked. The Plan denied your request. The Plan says the correct cost share applied to the claim.
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 $35 copayment for physician/practitioner services. You have been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the physician/practitioner 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 specialist office visit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eye examinations to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve eye exams. You say that your relationship with this physician is a key part of positive medical outcomes. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and you can be treated by an in-network ophthalmologist.

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 eye examinations to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).

You asked the Plan to pre-approve Durolane. You say that Durolane is medically necessary. The Plan denied your request. 

The Plan says a trial of 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 Durolane. Our reviewer says that Durolane is not medically necessary. Our physician reviewer found there is no record of a trial of the plan preferred drugs, or any documentation showing the plan preferred drugs would be unsafe or ineffective 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99213) provided on August 21, 2020.
You asked the Plan to pay for the office visit. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 an office visit (99213) provided on August 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient office visit provided by an out of network (OON) provider.
You asked the Plan to pay for the office visit. You say that the requested visit was medically necessary. The Plan denied your request. The Plan says criteria for obtaining out of network coverage have not been met.
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 the outpatient office visit provided by an out of network (OON) provider.