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

We decided that the Plan does not have to waive the copayment for OB/GYN services received on December 15, 2019.
You asked the Plan to waive the copayment for the services. You say that you have never paid a copayment for this before. The Plan denied your request. The Plan says the copayment was applied correctly according to your benefits and the services rendered.
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 $45 copayment for specialist office visits. You have been asked to pay a $45 copayment for the services. The services fall within the specialist office visits benefit category, as services were received that were beyond the standard Medicare Preventive Pap Tests screening services. 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 OB/GYN services received on December 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from January 26, 2020 through January 28, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department (ED) and/or observation care) would span two midnights. 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 the acute inpatient hospital care provided from January 26, 2020 through January 28, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Zilretta injection and arthrocentesis.
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says there is a lack of documentation of effectiveness of viscosupplementation injection of the large joints for the enrollee.
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 the requested services. Our physician reviewer found the enrollee has end-stage bilateral knee osteoarthritis, a history of diabetes mellitus, and obesity. The enrollee received bilateral knee injections with Zilretta, and has had excellent relief until recently. She is hesitant to proceed with surgery at this time. Zilretta is indicated for the management of knee pain due to osteoarthritis and is not intended for repeat administration and can only be used once per knee per lifetime. The efficacy and safety of repeat administration of Zilretta have not been demonstrated. Consequently, the aspiration and/or injection of large joint is not indicated in this case. 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Zilretta injection and arthrocentesis.
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 December 24, 2019 to December 31, 2019.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.
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, the claim is missing a valid Federal Information Processing Standards (FIPS) code. A valid FIPS code is required to process the claim. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from December 24, 2019 to December 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided on February 13, 2020.
You asked the Plan to waive the copayment for a CT scan. You say that you should only owe a $15 copayment. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $150 copayment for advanced imaging services. You have been asked to pay a $150 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 CT scan provided on February 13, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on February 13, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that the doctor is in-network. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these services.
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 lab work provided on February 13, 2020 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve hyperthermia intraperitoneal chemotherapy (HIPEC) for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered when used alone, or together with chemotherapy.
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 per NEJM 1/18/2018 378:230-240, among patients with stage III epithelial ovary ca, the addition of HIPEC to interval cytoreductive surgery resulted in longer recurrence free survival and overall survival than surgery alone without higher rates of side 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 procedure have been met. Therefore, we decided that the Plan has to pre-approve hyperthermia intraperitoneal chemotherapy (HIPEC) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX injections for the enrollee.
You asked the Plan to pre-approve Supartz FX. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that there was no evidence that the enrollee has tried and failed a trial of Orthovisc and Monovisc.
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 Supartz FX. Our reviewer says that Supartz FX is not medically reasonable and necessary for the enrollee. Supartz FX is being requested for the treatment of bilateral primary osteoarthritis of the knee. The enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Supartz FX. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX injections 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 December 18, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that this is a hardship for you. The Plan denied your request. The Plan says that there is no provision in your Evidence of Coverage about the waiver of co-payments.
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 $200 copayment for per one-way ambulance trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the one-way ambulance trip 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 December 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 21, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.
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 October 21, 2019 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 transit kit for the enrollee's wheelchair.
You asked the Plan to pre-approve a transit kit. The Plan denied your request. The Plan says the transit kit is not considered durable medical equipment as it is for use outside the home only.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a transit kit for the enrollee's wheelchair.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from September 9, 2019 to September 12, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says a corrected claim is needed for the claim can be reprocessed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of the denied codes is: HCPCS G0151: Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes HCPCS G0299: Direct skilled nursing services of a registered nurse (rn) in the home health or hospice setting, each 15 minutes We find that the denied codes are not supported in the medical record. Specifically, the claim was billed with an incorrect type of bill code. 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 for home health services provided to the enrollee from September 9, 2019 to September 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan.
You asked the Plan to pre-approve Rituxan. You say that you do not carry the biosimilar to Rituxan. The Plan denied your request. The Plan says the enrollee has not first tried and had a contraindication or intolerance to Truxima or Ruxience.
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 Rituxan. Our reviewer says that criteria for this drug is not met. Our physician reviewer found the provided medical records do not indicate that the enrollee has tried and failed the required drugs. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects 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 Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 85060) provided on February 6, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not payable.
The Plan must follow Medicare rules. Medicare rules say that a Professional Component (PC)/Technical Component (TC) Indicator of 8 identifies the professional component of clinical laboratory codes for which separate payment may be made only if the physician interprets an abnormal smear for hospital inpatient. We looked at the file and Medicare rules. CPT code 85060 has a PC/TC indicator of 8. This means that the professional component of this procedure is only payable for inpatients. The services were billed with an outpatient place of service. Payment for this service cannot be made for hospital outpatients. 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 for the services (CPT 85060) provided on February 6, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray (D0330), the complete upper denture (D5110), and the complete lower denture (D5120) provided on December 9, 2019.
You asked the Plan to pay for the dental services. You say that the original set of dentures that you received have never fit your mouth. You say that your dentist advised they could do a re-align for $200 per set but you cannot afford that. You say another dentist made you dentures that fit perfectly. You also say you advised the Plan that they should not pay for the original set of dentures you received. The Plan denied your request. The Plan says panoramic x-rays are covered once every 36 months. The Plan says dentures are covered once every 60 months. The Plan also says the frequency limits for these services have 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 and panoramic x-rays and dentures are covered services, the frequency limits for these services have been exceeded. The record shows that the Plan paid for a panoramic x-ray that you received on July 17, 2017, a complete upper denture that you received on December 17, 2017, and a complete lower denture that you received on March 1, 2018. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330), the complete upper denture (D5110), and the complete lower denture (D5120) provided on December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) sensor kit.
You asked the Plan to pre-approve continuous glucose monitor. You say that the enrollee checks blood sugar and inject insulin twice per day. The Plan denied your request. The Plan says the denial of authorization for these supplies is correct, because the enrollee does not meet the criteria for a continuous glucose monitor.
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered when they are considered medically 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 continuous glucose monitor. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested continuous glucose monitor (CGM) supplies. Our physician reviewer found the enrollee is noted to be a non-compliant Type 2 diabetic, who uses oral medications and insulin to treat her diabetes. There is no documentation of how often the enrollee checks her blood glucose level. There is no evidence that the enrollee uses the results of blood glucose testing to self-adjust self-administered insulin multiple times per day. As such, the documentation does not support that the use of a CGM is medically reasonable or 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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) sensor kit.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and x-ray services provided on September 9, 2019.
You asked the Plan to pay for the office visit and x-ray services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received are not a covered benefit.
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 the office visit and x-ray services provided on September 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of an erupted tooth requiring removal of bone and/or sectioning of tooth and two extractions of an erupted tooth or exposed roots provided on November 13, 2019 and November 20, 2019.
You asked the Plan to pay for the extractions. You say that you had to be penalized because the provider refused continuing a treatment. The Plan denied your request. The Plan says the benefits for these services had been satisfied and the frequency limitation had 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, extractions are limited to two procedures per calendar year. The record shows that you received extractions on April 19, 2019 and October 16, 2019 and your extractions benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for the extraction of an erupted tooth requiring removal of bone and/or sectioning of tooth and two extractions of an erupted tooth or exposed roots provided on November 13, 2019 and November 20, 2019.