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

 We decided that the Plan does not have to waive the copayment for an injection of dalbavancin (J0875), provided on August 17, 2021.0  You asked the Plan to waive the copayment for an injection of dalbavancin. You say that the service should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare Part B prescription drugs.   You have been asked to pay a 20% coinsurance for an injection of dalbavancin. an injection of dalbavancin falls within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan.    This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an injection of dalbavancin (J0875), provided on August 17, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Qvar Redihaler.  You asked the Plan to pre-approve Qvar Redihaler. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Qvar Redihaler.   Benefits for Qvar Redihaler may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on May 13, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that services were provided to the enrollee so payment should be processed. The Plan denied your request. The Plan says there was no prior authorization obtained for the enrollee to get services from an out-of-network 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 an office visit provided on May 13, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve treatment with Rocklatan drops.  You asked the Plan to pre-approve Rocklatan. You say that the requested treatment is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for self-administered drugs have not been met.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Rocklatan drops.   Benefits for Rocklatan may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit provided on October 1, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit. You say that services were provided to the enrollee so payment should be made. The Plan denied your request. The Plan says there was no prior authorization obtained and services provided were from a non-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 an office visit provided on October 1, 2020, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for the prosthetic devices and related supplies provided from January 4, 2021, through September 9, 2021.  You asked the Plan to waive the coinsurance for the prosthetic devices and related supplies. You say that the items should be covered. The Plan denied your request. The Plan says the cost share was applied correctly.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Prosthetic Devices and Related Supplies.      You have been asked to pay a 20% coinsurance for the prosthetic devices and related supplies. These items fall within the Prosthetic Devices and Related 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 coinsurance for the prosthetic devices and related supplies provided from January 4, 2021, through September 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eyeglasses (V2781, V2020, V2750) purchased on August 31, 2021.  You asked the Plan to pay for the eyeglasses. You say that your prescription changes frequently and you need new glasses every year. You say this has never been an issue before. The Plan denied your request. The Plan says your benefit covers up to $300 toward the cost of routine eyewear every 2 years. You previously used this benefit in August of 2020, and therefore you had exhausted your benefit prior to the date in question.  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services once every 2 years.  We looked at the file and the Plan's rules. The record shows that it has been less than two years since you last used your routine eyewear benefit. Based on this information, we decided that the Plan's rules for coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to pay for the eyeglasses (V2781, V2020, V2750) purchased on August 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on August 16, 2021.  You asked the Plan to pay for the compression stockings. You say that the item is medically necessary. The Plan denied your request. The Plan says this is not a covered item.  The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing.   Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on August 16, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ferumoxytol (Q0138).  You asked the Plan to pre-approve Ferumoxytol. The Plan denied your request. The Plan says this request does not meet the Plan's Part B step therapy criteria for Ferumoxytol (Q0138).  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 Ferumoxytol. Our reviewer says that this drug is not medically reasonable and necessary for the enrollee. Our physician reviewer found the Plan requires a trial of drugs Infed (Iron Dextran) and Venofer (Iron Sucrose) before they will approve the requested drug. Our reviewer found that in this case, the enrollee has not tried and failed the required drugs. Our physician reviewer also found that there is no documentation provided indicating 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 Ferumoxytol have not been met. Therefore, we decided that the Plan does not have to pre-approve Ferumoxytol (Q0138).
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an emergency room visit provided on October 3, 2021.  You asked the Plan to waive the copayment for an emergency room visit. You say that your oncologist advised you to see a doctor immediately if cellulitis occurs in your arm. You also say that the initial treatment received did not provide relief. The Plan denied your request. The Plan says the cost-share was applied correctly according to your emergency care benefit. The Plan also says the services were received without prior contact to the Plan regarding the cost-share.  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 $65 copayment for Emergency Care.       You have been asked to pay a $65 copayment for an emergency room visit. The services at issue fall within the Emergency 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 an emergency room visit provided on October 3, 2021.   Your complaint about potentially receiving insufficient care is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve LTACH services. You say that the requested LTACH services are a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for LTACH services have not been met.  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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where the enrollee is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the 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 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for moderate sedation services (99153) and percutaneous transcatheter placement (92929) provided on July 9, 2020.  You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the provider has not billed this claim as required by Medicare coding regulations.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We looked at the file and Medicare rules. Specifically, code 99153 has a Professional Component (PC)/Technical Component (TC) indicator of 3. CPT code 99153 was established as a practice expense-only code meaning there is no work component relative value units (RVU) associated with that service. The technical component will not be paid to the physician when performed in a facility setting. This means that payment for this service is the responsibility of the facility to any vendor.    Regarding CPT code 92929, this code has a status indicator of "B" indicating it is a bundled code where no separate payment is made for the services rendered.  Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153) and percutaneous transcatheter placement (92929) provided on July 9, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99213) provided on July 2, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visit. You say that you would like this claim reprocessed as the enrollee resides in a state outside her Plan area The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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's record has the enrollee's primary residence in their service area. 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 office visit (99213) provided on July 2, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pneumatic compression device provided on September 17, 2021.  You asked the Plan to pay for the services provided. You say that the device is required to prevent blood clots. The Plan denied your request. The Plan says the service is not covered by Medicare or your Plan.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We looked at the file, and Medicare rules. The file shows that you received a pneumatic compression device and related accessories during a surgical procedure. A pneumatic compression device for the prevention of blood clots is a preventive service. Items that are used for a preventative service or function are excluded from coverage under the Medicare DME benefit.   Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device provided on September 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a portable oxygen concentrator.  You asked the Plan to pre-approve a portable oxygen concentrator. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested item is not medically necessary.  The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify for oxygen solely based on blood gas studies obtained during sleep.    To qualify for home oxygen, the patient must meet one of the following blood gas levels:  1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest;  2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;   3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise;  4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia.  For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, there is a rebuttable presumption of non-coverage.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a portable oxygen concentrator. Our reviewer says that the documentation does not support that the requested portable oxygen concentrator is medically reasonable or necessary. Our physician reviewer found you have chronic obstructive pulmonary disease (COPD). The medical records do not provide any oxygenation data.  Medicare criteria require documentation of hypoxemia during activity, and evidence of correction of the hypoxemia using an oxygen conserving device. Since this documentation was not provided, you do not meet criteria for the requested 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 a portable oxygen concentrator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable oxygen concentrator.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an epidural steroid injection.  You asked the Plan to pre-approve epidural steroid injection services. You say that these injection procedures are medically necessary for the enrollee's pain. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan follows Medicare rules. Medicare rules say that an epidural steroid injection (ESI) will be considered medically reasonable and necessary when the following requirements are met:  Lumber, cervical or thoracic radiculopathy, radicular pain and/or neurogenic claudication due to disc herniation, osteophyte or osteophyte complexes, severe degenerative disc disease, producing foraminal or central stenosis.  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 epidural steroid injection services. Our reviewer says that the requested epidural steroid injection services are not medically reasonable and necessary. Our physician reviewer found in this case, the magnetic resonance imaging (MRI) scan does not reveal severe degenerative joint disease producing foraminal or central spinal stenosis. The enrollee's MRI report states that there is no central stenosis and only mild bilateral foraminal stenosis at L2-3, L4-5, and L5-S1 (not caused by severe degenerative disc disease.) There is also no disc herniation noted or osteophyte complexes. Based on the provided documentation, the review has determined that the requested service is not 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 epidural steroid injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance and copayment for a collagenase injection and specialist office visit provided on August 24, 2020.  You asked the Plan to waive the coinsurance and copayment for the injection and specialist office visit. You say that you paid your $35 copayment and you also need your hand redone since the procedure did not work. The Plan denied your request. The Plan says the correct coinsurance and copayment were 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 prescription drugs, including injectable drugs.  Your contract with the Plan also clearly says that you must pay a $35 copayment for each specialist visit.   You have been asked to pay $1,825.34 for the injection, which is 20% of the allowed amount ($9,126.72 allowed amount x 20% coinsurance = $1,825.34). The injection falls within the Medicare Part B Prescription Drugs benefit category. You have also been asked to pay a $35 copayment for the specialist office visit. The specialist office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance and copayment for a collagenase injection and specialist office visit provided on August 24, 2020.