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

We decided that the Plan does not have to pre-approve Actemra 200mg/10ml solution (J3262). 
 
You asked the Plan to pre-approve Actemra 200mg/10ml solution (J3262). You say that the service is 
medically necessary. The Plan denied your request. The Plan says Medicare references do not support this use 
for the intravenous (IV) product. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Actemra 200mg/10ml solution (J3262). 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the medication is 
not approved for IV administration. IV administration is not supported by one of the major drug compendia or 
by clinical research that appears in a CMS-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Actemra 200mg/10ml solution (J3262) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve Actemra 200mg/10ml solution (J3262).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvegingivectomy/gingivoplasty (D4212 x 5), a bone replacement graft (D7953 x 2), and gingival irrigation (D4921).You asked the Plan to pre-approvethe gingivectomy/gingivoplasty, bone replacement graft, and gingival irrigation. You say that the services are medically necessary.The Plan denied your request. The Plan says gingivectomy/gingivoplasty is not listed as a covered service. The Plan says that bone replacement graft is not listed as a covered service. The Plan also says that gingival irrigation is not listed as a covered service.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvegingivectomy/gingivoplasty (D4212 x 5), a bone replacement graft (D7953 x 2), and gingival irrigation (D4921).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea total electric hospital bed for the enrollee.You asked the Planto pre-approvethe bed. You say that it is very difficult to care for the enrollee.The Plandenied your request. The Plansaysthis type of bed is not meant for use outside of the hospital.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offerscoverage for this item.Therefore, we decided that the Plandoes not haveto pre-approvea total electric hospital bed for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvetransthoracic echocardiography for the enrollee.You asked the Plan to pre-approvethe procedure. You say that this is medically necessary.The Plan denied your request. The Plan says that medical necessity criteria has not been met.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 procedure. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is six months status post TVR. There are multiple issues that need to be ascertained at the six month echo including asymptomatic paravalvular leaks and regirgitation, migration of the prosthesis, thrombus, aortic dissection, etc. Standard guideline recommendations fromEuropean Society of Cardiology and the Valve Academic Research Consortium recommend echocardiography at 30 days, (done Aug 2020), six months (current echo under dispute) and then yearly thereafter. The echocardiogram being ordered is the standard, guideline recommended six month post TAVR procedure echo and meets criteria for medical necessity in 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 procedure have been met.Therefore, we decided that the Plan has to pre-approvetransthoracic echocardiography 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 toopen the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power seat lift chair.You asked the Plan to pre-approvea power seat lift 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 medically necessary.The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed above are met.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 power seat lift chair. Our reviewer says that the documentation does not support that the requested power seat lift chair is medically reasonable or necessary. Our physician reviewer found the documentation does not reveal objective evidence that you have severe arthritis of the hip. The documentation does not reveal that you have a neuromuscular disease. The documentation does not indicate a seat lift is recommended by the November 2, 2020,physical therapy evaluation. The documentation does not support that a seat lift is likely to effect improvement in your condition or arrest or retard deterioration in your condition. The records do not indicate that the you are able to stand from a standard seat height. The records do indicate that you can ambulate. Therefore, you do not meet criteria for the requested item.We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of a power seat lift chair have not been met.Therefore, we decided that the Plan does not have to pre-approvea power seat lift chair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the outpatient office visit (99212) provided 
August 28, 2020. 
 
You asked the Plan to waive the copayment for the office visit. You say that you had an allergy test done on 
8/24-8/28. You are contesting the copay charged on 8/28/2020 as it was all part of the allergy testing. The Plan 
denied your request. The Plan says this claim was processed and the correct copayment applied per the 
Evidence of Coverage. 
 
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 $35 
copay for each specialist visit.  
 
You have been asked to pay $35 copay for each specialist visit. The office visit falls within the 
Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been 
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have 
to waive the copayment for the outpatient office visit (99212) provided August 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services provided on May 11, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says it cannot be determined how the member came to the servicing provider, or whether the services are medically necessary.The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. The documentation submitted does not contain medical records from the non-contract provider. Without records, it cannot be determined that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services provided on May 11, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays provided on September 22, 2020.
You asked the Plan to pay for the bitewing x-rays. You say that you feel you should not owe any money because you were advised x-rays were needed. The Plan denied your request. The Plan says your bitewing x-rays benefit had been exhausted. The Plan also says that you signed a treatment plan with your dentist indicating that you acknowledged and accepted financial responsibility prior to receiving the dental service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, bitewing x-rays are limited to one set per calendar year. The record shows that you received bitewing x-rays on January 15, 2020, and your bitewing x-rays benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays provided on September 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient office visits provided October 30, 2019 to June 2, 2020
You asked the Plan to waive the copayment for the outpatient office visits. You say that when you went to these appointments you were told that they were a part of your well checks and there was no copay. The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.
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 $45 copay for each specialist visit. You have been asked to pay $45 copay for the outpatient office visits. The outpatient office visits fall within the Physician/Practitioner services, including doctor's office visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient office visits provided October 30, 2019 to June 2, 2020
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveProlia.You asked the Plan to pre-approveProlia. You say that you would like reconsideration because this drug is medically necessary.The Plan denied your request. The Plan says the member does not meet step therapy exception criteria.Medicare covers Part B medications when they are reasonable and necessary but allows healthplans 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 Prolia. Our reviewer says that the documentation does not support that the member has a history of osteoporotic fracture or previous treatment, contraindication, or intolerance to zoledronic acid. Our physician reviewer found step therapy, as outlined by the plan, requires this documentation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forout-of-network (OON) mental health services (90791) provided on January 9, 2020.You asked the Plan to waive the coinsurance forOON mental health services. You say that you don't believe you had this service.The Plan denied your request. The Plan says this service processed correctly.The rules say a plan must disclose to its enrollees inclear, 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% coinsurance for out-of-network mental health care. You have been asked to pay a 30% coinsurance for OON mental health services. The medical records confirmed the billed service took place. 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 forout-of-network (OON) mental health services (90791) provided on January 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B drug administration provided on July 30, 2020.You asked the Plan to waive the coinsurance forthe Part B drug administration. You say that there should not be a cost share for the service.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 Medicare Part B prescription drugs. You have been asked to pay 20% coinsurance for the Part B drug administration. The Part B drug administration falls 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 forthe Part B drug administration provided on July 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe outpatient hospital services rendered on August 3, 2020.You asked the Plan to waive the copayment forthese services. You say that you shouldn't be responsible.The Plan denied your request. The Plan says the copayment was 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 $300 copayment for outpatient observation services. Review of the file shows that you received outpatient observation services after your evaluation in the emergency room on August 3, 2020. You have been asked to pay a $300 copayment for these services. These services fall within the outpatient observation 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 forthe outpatient hospital services rendered on August 3, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the cystoscopy (52000) provided on September 3, 2020.You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.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 $600 copayment per visit for outpatient surgery, included services provided at in-network hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $548.22 copayment for the outpatient surgery provided. This is the Plan allowed amount which is less than the applicable copayment for this service. 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 copaymentfor the cystoscopy (52000) provided on September 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan
rendered on August 5, 2020.
You asked the Plan to waive the copayment for these services. You say that you would like the plan to pay for
the procedure. The Plan denied your request. The Plan says the copayment was 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 $150
copayment for each Medicare-covered radiological diagnostic service, not including x-rays.
Review of the file shows that you received a CT scan of the face on August 5, 2020. Per the contract with the
Plan, there is a $150 copayment for each Medicare-covered radiological diagnostic service, not including xrays.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However,
the Medicare allowed amount for these services was $133.07. Given that the allowed amount was less than the
$150 copayment, you have been asked to pay $133.07 for these services.
Therefore, we decided that the Plan does not have to waive the copayment for the computed tomography (CT)
scan rendered on August 5, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81251, 81401, 81406, 81405, 81404) provided on April 26, 2020 by an out of network (OON) provider.

You asked the Plan to pay for OON laboratory services. You say that these services were medically necessary. The Plan denied your request. The Plan says these 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 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 laboratory services (81251, 81401, 81406, 81405, 81404) provided on April 26, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested admission is not medically necessary.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 enrollee was admitted to the acute inpatient setting for the treatment of a scrotal abscess. The enrollee required intubation for COVID related acute respiratory failure. The enrollee has not required prolonged mechanical ventilation. The enrollee was successfully extubated. The documentation does not support long-term enteral feeding access is stable. The enrollee underwent placement of a PEG tube. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation and complete series of intraoral x-rays provided on December 26, 2019 by an OON provider.You asked the Plan to pay forthe comprehensive oral evaluation and complete series of intraoral x-rays. You say that you contacted the Plan for information on a dentist office you could go to so you could get your yearly cleaning and exam, and were told this provider was in-network.The Plan denied your request. The Plan says these services were rendered by an OON provider. The Plan also says that these services are not covered when rendered by a dentist who does not participate in the Plan's program.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. The records show that only one phone call had been received from you, and only your ID card was requested to be resent.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation and complete series of intraoral x-rays provided on December 26, 2019 by an OON provider.