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

We decided that the Plan does not have to pre-approve Tecentriq.

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 services are not medically necessary.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has hepatocellular cancer. Tecentriq is FDA-approved for the treatment of unresectable or metastatic hepatocellular carcinoma (in combination with bevacizumab) in patients who have not received prior systemic therapy. This enrollee has received at least two prior systemic therapies: sorafenib and nivolumab with lenvatinib. The service 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-approve Tecentriq.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the colonoscopy provided on November 10,
2020.

You asked the Plan to waive the cost share for the colonoscopy. You say that you should not be responsible for
any charges related to the colonoscopy. The Plan denied your request. The Plan says you have been asked to
pay 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 $300 deductible that applies towards an in-network diagnostic
colonoscopy and 10% coinsurance for each in-network Medicare-covered ambulatory surgical center visit after
your yearly deductible is met.

The diagnostic colonoscopy you asked the Plan to waive the cost share for falls within the "Outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category.

The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible that
applies towards an in-network diagnostic colonoscopy and 10% coinsurance for each in-network Medicare covered
ambulatory surgical center visit. The medical record shows the colonoscopy was performed due to a
personal history of colonic polyps and a positive Cologuard test. The record also shows two polyps were
removed which makes the colonoscopy diagnostic in nature. See chart below.

Date of Service
November 10, 2020

Service
Colonoscopy

Allowed Amount
$493.97
$193.97 - This is the remaining allowed amount after the deductible was met

Deductible/Coinsurance
$300
10%

Member Liability
$300
$19.40

Total
$319.40

This cost sharing is a contractual obligation that had not been met at the time the colonoscopy was received on November 10, 2020. Therefore, we decided that the Plan does not have to waive the cost share for the colonoscopy provided on November 10, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services.

You asked the Plan to pay for the home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home health services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided by an OON provider.

You asked the Plan to pay for the additional intraoral periapical x-ray. You say that you believed 50% of this service would be covered. The Plan denied your request. The Plan says benefits for this service had been satisfied and the frequency limitation had been exceeded. The Plan also says that you did not contact the Plan prior to this date of service to verify benefits and provider eligibility.

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, intraoral x-rays are limited to one procedure per calendar year. The record shows that you received a first intraoral periapical x-ray and your intraoral x-rays benefit had been exhausted. You are also responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the additional intraoral periapical x-ray provided by an OON
provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation (A0120).

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says this service is not a covered benefit under your contractual policy or by Medicare.

The Plan must follow Medicare rules. Medicare does not cover transport in a vehicle that is not an ambulance. The Plan follows the same rule. 

We looked at your request, the records in the case file, and the rules. Based on this information, we decided that the Medicare rules for coverage of this service have not been met. Therefore, we decided that the Plan does not have to pre-approve routine transportation (A0120).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit you had with an ophthalmology specialist.

You asked the Plan to waive the copayment for the office visit. You say that this claim should be paid in full. The Plan denied your request. The Plan says this claim has paid appropriately and you were charged the correct copayment for this visit.

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 $20 copayment for services in a specialist's office.

You have been asked to pay a $20 copayment for the office visit. The office visit falls within the services in a specialist's office 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 office visit you had with an ophthalmology specialist.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services.

You asked the Plan to pay for the home health services. You say that you feel that you should be reimbursed for this care because it was necessary. The Plan denied your request. The Plan says you did not meet Medicare coverage criteria for home health care.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.

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 the home health services. Our reviewer says that the records do not support the medical necessity of the home health provided. Our physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Therefore, the provision of home health services was not medically necessary, reasonable or coverable.

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 home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided by an out of network (OON) provider.

You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by a participating 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 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 physician services provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services.

You asked the Plan to pay for the anesthesia services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that has been documented.

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 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 anesthesia services.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the F'1LCDx test.

You asked the Plan to pay for the F'1LCDx test. You say that you are the developer and sole provider of this test. The Plan denied your request. The Plan says that a Medicare plan may not pay for services given by a physician or other practitioner who has opted out of Medicare or who is not eligible to accept Medicare payment.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Opt-out is only available to providers that are considered physicians by Medicare rules. Facilities or labs are not subject to opting out. Also, the Plan has not provided any evidence that would indicate that this lab is not Medicare certified. Therefore, we decided that the Plan has to pay for the F'1LCDx test.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visit.

You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.

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 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 hospital outpatient clinic visit.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services.

You asked the Plan to pay for the inpatient hospital services. You say that the inpatient hospital services was medically necessary. The Plan denied your request. The Plan says that the inpatient hospital services was not medically necessary.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 the inpatient hospital services. Our reviewer says that the inpatient hospital services was medically necessary. Our physician reviewer found the review indicates the treating physician did document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer. For dates of service where the treating physician has determined that the enrollee is not stabilized for transfer, this decision is binding on 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 inpatient hospital services have been met. Therefore, we decided that the Plan has to pay for the inpatient hospital services.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on April 28, 2019.
You asked the Plan to pay for the SNF services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service. The record shows that a claim for the SNF services was not filed until October 8, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on April 28, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a P-Stim device.
You asked the Plan to pre-approve a P-Stim device. You say that the item is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that acupuncture for stimulation of auricular points is not a covered Medicare benefit. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a P-Stim device have not been met. Therefore, we decided that the Plan does not have to pre-approve a P-Stim device.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the computed tomography (CT) scan of the abdomen and pelvis you had on November 27, 2020.

You asked the Plan to waive the coinsurance for the CT scan. You say that you cannot afford this cost sharing. The Plan denied your request. The Plan says you were charged this cost sharing 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, up to a maximum of $75 per day for diagnostic radiology services. 

You have been asked to pay 20% coinsurance, up to a maximum of $75 per day for the CT scan. The CT scan falls within the diagnostic radiology 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 coinsurance for the computed tomography (CT) scan of the abdomen and pelvis you had on November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam of two surfaces and addition of tooth to an existing partial denture, or pay more for the amalgam of one surface and resin-based composite provided on November 23, 2020, and December 7, 2020.
You asked the Plan to pay for the amalgam of two surfaces and addition of tooth to an existing partial denture, and to pay more for the amalgam of one surface and resin-based composite. You say that you would like these services to be covered. The Plan denied your request. The Plan says the addition of tooth to an existing partial denture is not a covered benefit. The Plan also says that your restorations benefit 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, addition of tooth to an existing partial denture is not among those covered under this benefit. The contract says that restorations are limited to two procedures per calendar year, and you are responsible for a 55% coinsurance when the service is received OON. The record shows that you received an amalgam of one surface and a resin-based composite on November 23, 2020, and your restorations benefit had been exhausted. You are also responsible for the difference between the billed amount and allowed amount for services received OON. Therefore, we decided that the Plan does not have to pay for the amalgam of two surfaces and addition of tooth to an existing partial denture, or pay more for the amalgam of one surface and resin-based composite provided on November 23, 2020, and December 7, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from October 11, 2020, to November 10, 2020.
You asked the Plan to pay for the SNF care. You say that it is felt that Medicare payment should be made for these services. The Plan denied your request. The Plan says the criteria for Medicare coverage are not met for the dates at issue.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 pay for the SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission, the member required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of 10/11/2020 the member did not require any skilled nursing or rehab services on a daily basis. He was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or daily living activities. The member did not require
skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of 10/11/2020. 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from October 11, 2020, to November 10, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the contact lens fitting, and follow-up (92310).

You asked the Plan to pay for the contact lens fitting and follow-up. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services 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 says you are covered for one pair of standard eyeglasses or contact lenses every year. If you choose a participating provider, you have the benefit of $150 per calendar year applied at the time of service and would be responsible to pay for the balance.

We looked at your contract with the Plan. The contract says that you have a $150 benefit allowance for routine vision services. The Plan has not provided any documentation showing that you have exceeded this allowance. Therefore, we decided that the Plan has to pay for the contact lens fitting, and follow-up (92310).

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.