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

We decided that the Plan does not have to pre-approve dental services (D4249).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a covered benefit.
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-approve dental services (D4249).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for specialist visits provided on February 13, 2021, and February 14, 2021.
You asked the Plan to waive the copayments for specialist visits. You say that you were seen by several physicians in the hospital and none of them billed you. 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 $40 copayment for specialist visits. You received specialist services on February 13, 2021. Therefore, you are responsible to pay the $40 copayment. You received specialist services on February 14, 2021. Therefore, you are responsible to pay the allowed amount of $35.94, which is less than the $40 copayment.
The total amount you owe is: $75.94. You have been asked to pay the total copayment amount of $75.94 for specialist visits. Specialist 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 copayments for specialist visits provided on February 13, 2021, and February 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy, flexible; with biopsy, single or multiple (45380) provided on January 20, 2021.
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 $50 copayment for all other Medicare-covered outpatient diagnostic tests.
You have been asked to pay a $50 copayment for the outpatient diagnostic test provided. This means that you have been asked to pay the correct amount based on your contract with the Plan. This service is considered as a diagnostic test as a biopsy was performed. 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 colonoscopy, flexible; with biopsy, single or multiple (45380) provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve proton beam therapy.
You asked the Plan to pre-approve proton beam therapy. You say that the service is medically necessary. The Plan denied your request. The Plan says that there are no peer-reviewed medical literatures that support the use of Proton Beam Therapy as a sufficient means for prostate cancer.
The Plan follows Medicare rules. Medicare rules say that PBRT for treatment of certain conditions, such as prostate cancer without distant metastases, may be covered when performed by a provider who has demonstrated experience in data collection and analysis with a history of publication in the peer-reviewed medical literature. 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 proton beam therapy. Our reviewer says that the enrollee meets the criteria for this service. Our physician reviewer found that physician documentation of the patient's "stage and other factors" (which would include Gleason score and PSA) and documentation of the range of therapy choices are documented in the consultation notes. Also, the physician has demonstrated experience in data collection and analysis with a history of publication in the peer-reviewed medical literature. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have been met. Specifically, the provider has demonstrated experience in data collection and has provided documentation of patient selection criteria and therapy choices. Therefore, we decided that the Plan has to pre-approve proton beam therapy.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on January 24, 2021.
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 24, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on January 24, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on September 4, 2020.
You asked the Plan to waive the copayment for an EGD. You say that you were told that you would only owe a $50 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 $200 copayment for outpatient surgery, including services provided at ambulatory surgical centers. You received an EGD at an ambulatory surgical center on September 4, 2020. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $200 copayment.
You have been asked to pay a $200 copayment for an EGD. An EGD falls within the outpatient surgery,
including services provided at hospital outpatient facilities and ambulatory surgical centers 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 an EGD provided on September 4, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit with a specialist (99214) provided on March 2, 2020.
You asked the Plan to waive the copayment for an office visit. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment you are being charged is correct.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for physician/practitioner services, including doctor's office visits with a specialist.
You have been asked to pay a $35 copayment for an office visit. The EOC confirms $35 is the required copayment for this service. An office visit with a specialist 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 an office visit with a specialist (99214) provided on March 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the removal of a subcutaneous cardiac
rhythm monitor provided on October 14, 2020.
You asked the Plan to waive the coinsurance for the removal of a subcutaneous cardiac rhythm monitor. You
say that you disagree with how high the charges are because the procedure only took 45 minutes. 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 20%
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You received the removal of a subcutaneous cardiac rhythm monitor at an outpatient hospital facility on October 14, 2020. The removal of a subcutaneous cardiac rhythm monitor is considered an outpatient surgical procedure. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $3,532.37 and 20% of that is $706.47. You have been asked to pay the total coinsurance amount of $706.47 for the removal of a subcutaneous cardiac rhythm monitor. The removal of a subcutaneous cardiac rhythm monitor falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 removal of a subcutaneous cardiac rhythm monitor provided on October 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement cover for wheelchair seat cushion or back cushion (E2619).
You asked the Plan to pre-approve a replacement cover. You say that this is medically necessary. The Plan denied your request. The Plan says that a replacement cover cannot be covered with initial issue.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a positioning wheelchair back cushion (E2620) and a skin protection and positioning wheelchair seat cushion (E2624). A positioning wheelchair back cushion (E2620) and a skin protection and positioning wheelchair seat cushion (E2624) serves the same purpose as a replacement cover. Therefore, we decided that the Plan does not have to pre-approve a replacement cover for wheelchair seat cushion or back cushion (E2619).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there appears to be some concerns that the devices are not as effective as surgical decompression, and lead to higher rates of reoperation.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy of the device.
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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to correct the copayment for eyeglass frames and lenses. We decided that the Plan
does not have to waive the copayment for eyeglass frames and lenses.
You asked the Plan to correct the copayment for eyeglass frames and lenses. You say that the provider is a
network provider and the Plan must therefore apply the full $100 frames and lenses benefit to your purchase.
The Plan says that the correct copayment was applied.
We decided that the Plan has to correct the copayment for eyeglass frames and lenses.
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 enrollees must pay any amount over $100 retail price for purchase and fitting of
eyeglasses and pair of lenses at a network optical provider.
The Plan says you must pay any amount over $100 retail price for eyeglass frames and lenses. The Plan
contract states that the Plan must pay up to $100 for eyeglass frames and lenses. However, the case record
indicates that the Plan has only paid $45 toward your purchase of eyeglass frames and lenses. Therefore, we
decided that the Plan has to correct the copayment for eyeglass frames and lenses.
We also decided that the Plan does not have to waive the copayment for eyeglass frames and lenses.
We have directed the Plan to correct the copayment for eyeglass frames and lenses. After the correction, your
responsibility for eyeglass frames and lenses will be $204.20. Eyeglass frames and lenses fall under the Plan's
mandatory supplemental vision benefit. This means that $204.20 is your correct cost sharing 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 eyeglass frames and
lenses.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider from November 11, 2020, to December 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says out-of-network services are not covered.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 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 services provided by an out-of-network provider from November 11, 2020, to December 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.
You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan denied your request. The Plan says that criteria for coverage has not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair and attachments.
You asked the Plan to pre-approve a Group 3 power wheelchair and attachments. You say that this is medically
necessary. The Plan denied your request. The Plan says that you do not have a qualifying diagnosis.
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for
enrollees who have a mobility limitation that is due to:
1. A neurological condition;
2. Myopathy; or
3. Congenital skeletal deformity.
The file does not show that you have a mobility limitation that is due to a neurological condition, myopathy or
congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a Group 3
power wheelchair and attachments
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory service (99195) provided on November 17, 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 $300 copayment for laboratory tests provided at an outpatient hospital facility. You have been asked to pay a $116.47 copayment for the laboratory service provided. This is the Plan allowed amount for this service and is less than the applicable copayment.
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 laboratory service (99195) provided on November 17, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Factor V (F5) Leiden testing (81241) provided on January
28, 2021.
You asked the Plan to pay for F5 Leiden testing. You say that this was a required test that needed to be done
before your surgery. The Plan denied your request. The Plan says the denial of payment for this testing is
correct, because this test is excluded from coverage except for pregnant patients.
The Plan must follow Medicare rules. Medicare rules say that F5 Leiden testing is excluded from coverage
outside of pregnant women under certain circumstances.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of F5 Leiden testing have not been met. Therefore, we decided that the Plan does not have to pay for
Factor V (F5) Leiden testing (81241) provided on January 28, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Part B coverage of the requested drug is subject to step therapy criteria.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the case file does not contain documentation of trail and failure of Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc would likely be less effective, and/or would likely have adverse effects for the enrollee 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve alginate wound dressings (A6197) to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve alginate wound dressings. You say that you are not sure if this provider is the only one that offers this service. You also say that you previously used a different provider, and the request was approved. The Plan denied your request. The Plan says there are in-network providers available for 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 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. The records provided for review do not show that the services at issue are urgent or emergent. 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 alginate wound dressings (A6197) to be provided by an out of network (OON) provider.