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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on April 22, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on April 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 23, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 services at issue in this appeal. 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 the medical services provided to the enrollee by an out-of-network provider on August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 15, 2020 by an out of network (OON) provider. You asked the Plan to pay for ophthalmology services. You say that you were told this provider was in-network with the Plan. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and you were referred by another out-of-network provider. 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. 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 January 15, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter.
You asked the Plan to pre-approve a power scooter. The Plan denied your request. The Plan says there is no record of exam, home study, or detailed written order.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. In this case, there is insufficient evidence to show that you have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair, or you that you can safely operate the PMD being requested. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided from July 5, 2019 to September 27, 2019.
You asked the Plan to waive the coinsurance for the Part B injections. You say that you are on a fixed income and cannot afford this. 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 20% coinsurance for Medicare Part B non-chemotherapy prescription drugs. You have been asked to pay $259.70 which is 20% of the allowed amount for the Part B injections on each date of service. The allowed amount is $1,298.52. ($1,298.52 x 20% = $259.70). ($259.70 x 4 = $1,038.80). The Part B injections fall within the "Medicare Part B prescription 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 Part B injections provided from July 5, 2019 to September 27, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve urinary incontinence sling surgery.
You asked the Plan to pre-approve urinary incontinence sling surgery . You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the requested services are not medically necessary.
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 urinary incontinence sling surgery . Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has documented stress urinary incontinence. The enrollee is status post total vaginal hysterectomy. A sling surgery is considered standard of care for this condition. Given that the enrollee has opted to undergo surgery for vaginal vault prolapse and rectocele, it is entirely reasonable to perform a concomitant sling procedure at the same time. Therefore, the enrollee meets criteria for the requested services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of urinary incontinence sling surgery have been met. Therefore, we decided that the Plan has to pre-approve urinary incontinence sling surgery.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from September 10, 2019 to September 29, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim has been submitted with an invalid Type of Bill code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim has been submitted with an invalid Type of Bill code.. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from September 10, 2019 to September 29, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Tacrolimus
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the drug is not eligible for a tier exception.
The Plan must follow Medicare rules. The rules say that if payment for a drug could be available under Part A or Part B to the individual for such drug, then it will not be covered under Part D. We looked at the file and Medicare rules. The requested drug is a Part B covered drug and this not eligible for a tier exception. 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 pre-approve a tier exception for Tacrolimus
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve an office visit. You say that you do not want to start over with a new physician. The Plan denied your request. The Plan says there is no network deficiency for these services and alternate network providers were found.
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 an office visit 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 Injectafer for the enrollee.
You asked the Plan to pre-approve Injectafer. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the enrollee does not meet criteria for Injectafer.
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 Injectafer. Our reviewer says that Injectafer is not medically reasonable and necessary for the enrollee. There has not been documentation of an adequate trial of (or intolerance to) oral iron supplementation. There is nothing in the medical records provided to raise concern that Injectafer would not be safe or effective for the patient at this time but there has not been documentation of an adequate trial of (or intolerance to) oral iron supplementation prior to this treatment. Our physician reviewer found the enrollee's condition does not meet criteria for coverage of Injectafer. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have to pre-approve Injectafer for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional services for a clinical trial.
You asked the Plan to pre-approve the requested services. You say that you need treatment as soon as possible. The Plan denied your request. The Plan says Original Medicare pays most of the cost of the covered services in a clinical trial.
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, an additional office visit and consultation was requested as part of a clinical trial. The Plan does not cover routine costs and services associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve additional services for a clinical trial.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for podiatry services provided to the enrollee on October 8, 2019.
You asked the Plan to pay for podiatry services. You say that the claims should be paid. The Plan denied your request. The Plan says during the election, fee-for-service Medicare covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for podiatry services provided to the enrollee on October 8, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the eyeglasses purchased on December 11, 2019.
You asked the Plan to pay for the vision services. You say that your claim for $200 towards the frames was denied. You paid $321 towards the new glasses and was surprised that you claim was denied. The Plan denied your request. The Plan says the benefit maximum has been exceeded.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when up to $250 every year for eyeglasses, frames, lenses or contact lenses from an in-network provider. We looked at the file and the Plan's rules. The plan pays up to $250 every year for eyeglasses, frames, lenses or contact lenses from an in-network provider. The plan has paid the the $250 allowed for this benefit. 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 the eyeglasses purchased on December 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea shower chair.You asked the Plan to pre-approvea shower chair. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested 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-approvea shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for immediate lower denture (D5140) provided August 12, 2019.
You asked the Plan to pay for the dental services. You say that you feel that the plan has underpaid you and is not willing to help you get this issue resolved. The Plan denied your request. The Plan says this request exceeds the allowed maximum benefit limit.
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. Records show that the plan reimbursed $550 on October 9, 2019 which was cashed October 21, 2019 and $450 on December 30, 2019 which was cashed on January 8, 2020. Therefore the entire $1000 annual allowance has been paid. Therefore, we decided that the Plan does not have to pay for immediate lower denture (D5140) provided August 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued care with an out-of-network cardiologist.
You asked the Plan to pre-approve continued care with an out-of-network cardiologist. You say that the continued care with an out-of-network cardiologist is medically necessary. The Plan denied your request. The Plan says the follow-up cardiology care can be safely transferred to an in-network cardiologist.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care. 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 continued care with an out-of-network cardiologist. Our reviewer says that the follow-up cardiology care can be safely transferred to an in-network cardiologist. Our physician reviewer found the enrollee is with a history of hypertension, cerebral aneurysm, muscular dystrophy and pacemaker placement. She saw her out-of-network cardiologist on 08/16/2019 for scheduled routine pacemaker follow up and reported no cardiac symptoms at that time. Based on the record the enrollee's cardiac status is documented to be clinically stable when during a routine pacemaker follow-up. In this circumstance of clinical stability, it would have been safe to transition the enrollee's cardiac care to an in-network provider. There is no documented unique condition that would make it medically necessary for the enrollee to continue her care with the out-of-network provider. An in-network board certified electrophysiologist should have expertise necessary to meet the standards of care required for treatment of the enrollee's condition. Therefore, the records do not support that continued care with the out-of-network provider is 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 continued care with an out-of-network cardiologist have not been met. Therefore, we decided that the Plan does not have to pre-approve continued care with an out-of-network cardiologist.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tadalafil for the enrollee. You asked the Plan to pre-approve Tadalafil. The Plan denied your request. The Plan says 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 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 Tadalafil for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEntyvio for the enrollee.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has long-segment non-dysplastic Barrett's esophagus, colon polyps, and sigmoid diverticulosis. He is asymptomatic, and the diagnosis of ulcerative colitis is uncertain based predominantly on the recent finding of focal cryptitis as seen in the distal left colon in the setting of C.difficile. The records do not show that he has tried and failed the Plan's required drugs of Remicade or Inflectra or that the required drugs would be less effective or contraindicated. Entyvio is therefore 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 pre-approveEntyvio for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe CT scan and the x-ray provided on October 11, 2019.You asked the Plan to waive the deductible forthe CT scan and the x-ray. You say that you were not aware that the provider was out-of-network. You say someone should have told you that they were not covered.The Plandenied 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. Your contract with the Plan says that there is a $500 deductible that applies to out-of-network CT scans and x-rays. The CT scan and x-ray you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that applies towards out-of-network CT scan and x-rays. The record shows that the provider is out-of-network.This cost sharing is a contractual obligation that had notbeen met at the time the CT scan and the x-ray were received on October 11, 2019.Therefore, we decided that the Plan does not have to waive the deductible forthe CT scan and the x-ray provided on October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pay the in network rate forthe 3 additional extractions (D7140) provided on November 18, 2019.You asked the Plan to pay the in network rate forthe additional 3 extractions. You say that only 2 extraction per year being covered is unheard of. You say that the provider failed to tell you that they were out of network with your plan. You also say that you were given this provider's information by a plan representative.The Plan denied your request. The Plan says 2 extractions per calendar year are covered. The Plan says the benefit for extractions has been exhausted.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 and extractions are a covered service, the extraction benefit has been exhausted. The record shows that the Plan paid the in network rate for 22 extractions that you received on November 18, 2019.Therefore, we decided that the Plan does not have to pay the in network rate forthe 3 additional extractions (D7140) provided on November 18, 2019.