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

We decided that the Plan does not have to pre-approve a tier exception for Hyalgan 20mg/2ml injection.
You asked the Plan to pre-approve the tier exception. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says products covered under the Part B benefit are not eligible for a lower copayment.
The Plan must follow Medicare rules. Medicare rules say that tiered cost-sharing means a process of grouping Part D drugs into different cost sharing levels within a Part D sponsor's formulary. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the tier exception have not been met. Specifically, because this drug is covered under Medicare Part B, it is not eligible for a tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Hyalgan 20mg/2ml injection.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for inpatient hospital care, a specialist visit (99214) and an electrocardiogram (93010) on December 4, 2020, through December 7, 2020, and December 23, 2020.
You asked the Plan to waive the copayments for inpatient hospital care, a specialist visit. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayments you are being charged are 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 $225 copayment per day for inpatient hospital care, a $25 copayment for a specialist visit and a $25 copay for an electrocardiogram.
You have been asked to pay a $225 copayment per day for inpatient hospital care ($225 x 3 days = $675). You have also been asked to pay a $25 copayment for a specialist visit. A specialist visit fall within the physician/practitioner services, including doctor's office visits benefit category. You have also been asked to pay a $8.43 copayment for an electrocardiogram, which is less than the billed charge. An electrocardiogram 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 copayments for inpatient hospital care, a specialist visit (99214) and an electrocardiogram (93010) on December 4, 2020, through December 7, 2020, and December 23, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the enrollee no longer has an illness that is complex enough to require further hospital care.
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. The patient appears to be improving and stable and should only require additional short-term acute care services which can be safely completed in the current facility. The patient does not require services at the LTACH that are not already available at the current facility. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea knee scooter.You asked the Plan to pre-approvea knee scooter. You say that a knee scooter will work best for you.The Plan denied your request. The Plan says a knee scooter is not considered medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked atthe file, and Medicare rules. A lower leg platform, with or without wheels will be denied as not medically necessary. Based on this information, we decided that Medicare rules for coverage have not been met.Therefore, we decided that the Plan does not have to pre-approvea knee scooter
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the surgical services provided on July 31, 2020, billed with codes 13101 and 13102.You asked the Plan to pay for the surgical services billed. You say that this should be paid.The Plan denied your request. The Plan says that code 13101 was not reviewed by the Plan. However, since 13101 was not paid, 13102 also cannot be paid as it is an add-on code.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 code 13101 is Repair, complex, trunk; 2.6 cm to 7.5 cm and the definition of code 13102 is Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure).We asked our coding 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 surgical services billed. Our reviewer says that the operative report supports the payment of both codes at issue. Our coding reviewer found the operative report clearly documents a complex repair measuring 20 cm, with layered closure.Therefore, this procedure was correctly billed.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical services billed have been met.Therefore, we decided that the Plan has to pay for the surgical services provided on July 31, 2020, billed with codes 13101 and 13102.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 waive the copayment for a medical eye exam provided on
March 9, 2021.
You asked the Plan to waive the copayment for the medical eye exam. The Plan denied your request. The Plan says the correct copayment was applied to the claim.
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 copayment for vision care.
You have been asked to pay $45 copayment for the medical eye exam. The medical eye exam falls within the vision care 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 medical eye exam provided on March 9, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services provided on March 24, 2019.

You asked the Plan to pay for the ambulance services. You say that the ambulance services in dispute were medically necessary. You say that you have made attempts to have the provider submit a claim. You say that you have made attempts to submit the additional information the Plan needs. The Plan denied your request. The Plan says that a valid corrected claim was not received from the provider after several attempts were made.

Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.

You were referred for the ambulance services by a contract provider. Specifically, the urgent care center that arranged the ambulance transport is participating with the Plan. The file does not show that the Plan provided notice that the ambulance services would not be covered. Under Medicare rules, this means the ambulance services is considered approved by the Plan. Therefore, we decided that the Plan has to pay for ambulance services provided on March 24, 2019.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a complete intraoral series of radiographic images (D0210), an unspecified adjunctive procedure (D9999), and periodontal scaling and root planing (D4341 x4) provided from November 23, 2020, through December 17, 2020.
You asked the Plan to pay for a comprehensive oral evaluation), a complete intraoral series of radiographic images, an unspecified adjunctive procedure, and periodontal scaling and root planing. You say that you do not understand why the services would not be covered, and you want the Plan to pay. The Plan denied your request. The Plan says you are responsible for services provided by privately contracted providers. The Plan will not reimburse for charges incurred by Medicare Opt Out providers.
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. We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation), a complete intraoral series of radiographic images, an unspecified adjunctive procedure, and periodontal scaling and root planing have not been met. Specifically, services were provided by an Opt out provider. The Plan does not cover dental services when provided by an Opt out provider. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a complete intraoral series of radiographic images (D0210), an unspecified adjunctive procedure (D9999), and periodontal scaling and root planing (D4341 x4) provided from November 23, 2020, through December 17, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says this service is not medically necessary.
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 this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that the Superion spacer remains 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 this service have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of a Superion interspinous stabilization device (22869, 22870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on January 6, 2021.
You asked the Plan to waive the deductible 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. Your contract with the Plan says that there is a $203 deductible for covered Part B services from both in-network and out-of-network providers. At the time this claim was processed, $0 of the $203 deductible had been met. The allowed amount of the claim is $105.07, resulting in a deductible obligation of $105.07. The service at issue is subject to the Plan deductible of $203. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a deductible for certain types of services from network providers. This cost sharing is a contractual obligation that had not been met at the time the office visit was received on January 6, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an office visit (99214) provided on January 6, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the hip orthosis provided on June 16, 2020.
You asked the Plan to pay for the hip orthosis (L1686). You say that the Plan should pay this claim. The Plan denied your request. The Plan says that there is no valid proof of delivery.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record contains a valid physician order and proof of delivery for the supplies provided in this case. There is an enrollee signed Proof of Delivery in the file. Therefore, we decided that the Plan has to pay for the hip orthosis provided on June 16, 2020.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 IRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital for seizure and respiratory failure. He is now medically stable with no complex nursing or rehabilitation needs.
He does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. He does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for chemotherapy (J9173, 96413) provided October 12, 2020.
You asked the Plan to waive the copayment for the chemotherapy. You say that the out-of-pocket maximum was met and the copayment should be waived. The Plan denied your request. The Plan says the record shows the out-of-pocket maximum was not met. The correct cost-sharing was applied.
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% coinsurance for Part B drugs.
You have been asked to pay a 20% coinsurance for the chemotherapy. The chemotherapy falls within the Part
B 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 copayment for chemotherapy (J9173,
96413) provided October 12, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vyepti.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the 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 a history of migraine headaches but the records do not document at least four migraine days per month, as required by the Plan's coverage policy. The records do not support that the Vyepti is reasonable or medically necessary at this time.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-approveVyepti.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient physical therapy from February 5, 2020, through March 11, 2020.
You asked the Plan to waive the copayment for outpatient physical therapy. 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 $40 copayment for each outpatient physical therapy visit. You have been asked to pay a $40 copayment for each outpatient physical therapy visit. You had nine (9) physical therapy visits ($40 x 9 = $360). Outpatient physical therapy falls within the outpatient rehabilitation 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 for outpatient physical therapy from February 5, 2020, through March 11, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lymphedema therapy to be provided by the requested
out-of-network provider.
You asked the Plan to pre-approve the Lymphedema therapy. The Plan denied your request. The Plan says with
limited exceptions, while you are a member of our Plan you must use network providers per your Plan's
Evidence of Coverage.
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 services at issue in this appeal. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve
Lymphedema therapy to be provided by the requested out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network nephrologist.
You asked the Plan to pre-approve these services. You say that you need to follow-up with this provider for dialysis. The Plan denied your request. The Plan says the services are available from network providers.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network nephrologist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation provided on January 12, 2021.
You asked the Plan to pay for the problem focused limited oral evaluation. You say that you feel the x-ray should have been covered. The Plan denied your request. The Plan says the problem focused limited oral evaluation is not covered. The Plan also says that you received an intraoral periapical x-ray on this date of service, which was covered by the Plan.
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 pay for the problem focused limited oral evaluation provided on January 12, 2021.