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

 We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on July 5, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the subsequent nursing facility care. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says the service provided required prior authorization for non-contracted providers. The Plan also says that prior authorization was not obtained.    Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan 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 subsequent nursing facility care (99309) provided on July 5, 2021 by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the non-emergency wheelchair van transport (A0130), and wheelchair van mileage (S0209) provided on August 16, 2020.  You asked the Plan to pay for the transportation services. You say that the enrollee's provider advised that professional transportation was extremely necessary. The Plan denied your request. The Plan says routine transportation is not covered under any condition.  The Plan must follow Medicare rules. The rules say that Medicare does not pay for wheelchair van transport services.   The services you have asked the Plan to pay for are wheelchair van transport services. Therefore, we decided that the Plan does not have to pay for the non-emergency wheelchair van transport (A0130), and wheelchair van mileage (S0209) provided on August 16, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eylea.  You asked the Plan to pre-approve Eylea. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet 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 Eylea. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has diagnoses of Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eye, and Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eye. The documentation does not support that the enrollee has tried and failed bevacizumab. The documentation does not support that bevacizumab 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 Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the coinsurance for collagenase injections provided on October 28, 2021.  You asked the Plan to waive the coinsurance for the injections. You say that the Plan representative informed you that the coinsurance would only be $200 per injection. The Plan denied your request. The Plan says the correct coinsurance 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 each Part B drug, including injectable drugs. Drug Allowed Amount 20% Coinsurance Collagenase 0.01 mg $3286.28 $657.26 Collagenase 0.01 mg $1813.12 $362.62 Total:  $1,019.88   You have been asked to pay $1,019.88, which is 20% of the allowed amount for the injections. The injections fall 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 coinsurance for collagenase injections provided on October 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on October 26, 2021.

You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says that the Plan paid the full supplemental eyewear allowance of $200, and the remaining balance is the member's responsibility.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows that the Plan paid the full supplemental eyewear allowance of $200, and the remaining balance is your responsibility. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the telephone evaluation and management service provided by an in-network provider on August 24, 2021.  You asked the Plan to waive the copayment for the telephone evaluation and management service. You say that you should not be charged for the telephone call during which you told the provider you would no longer need his services. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $20 copayment for using other in-network providers that have the ability and are qualified to offer virtual medical visits.   You have been asked to pay a $20 copayment for the telephone evaluation and management service. The telephone evaluation and management service falls within the "Virtual Doctors Visits" benefit category. The medical record shows the provider spent 11 minutes reviewing previous clinical information, evaluating the new images/reports, and discussing the findings. 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 telephone evaluation and management service provided by an in-network provider on August 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the core buildup, including any pins when required (D2950) and crown (D2740) provided on August 25, 2021, and September 28, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay more for the core buildup and crown. You say that you would like to appeal these services. The Plan denied your request. The Plan says the core buildup falls under the basic dental services benefit, and the crown falls under the major dental services benefit. The Plan also says that the treating provider can balance bill you for the difference between what was billed and what was paid because they are not an in-network provider.

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, you are responsible for a 20% coinsurance of the covered plan allowance for basic dental services after the $100 deductible is met, and you are responsible for a 50% coinsurance of the covered plan allowance for crowns after the $100 deductible is met. The core buildup has an allowed amount of $67, which was applied to the deductible. The crown has an allowed amount of $452.50. The remaining $33 of the deductible was applied, leaving a $419.50 allowance times 50% coinsurance which equals $209.75. You are also responsible for the difference between the billed amount and allowed amount because these services were received OON. Therefore, we decided that the Plan does not have to pay more for the core buildup, including any pins when required (D2950) and crown (D2740) provided on August 25, 2021, and September 28, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for periodontal maintenance (D4910) provided by a participating provider on September 28, 2021.

You asked the Plan to pay for periodontal maintenance. You say that you are covered three times a year for periodontal maintenance. You say that this was your third time. The Plan denied your request. The Plan says that the benefit limit for D4910 has already been exhausted.

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. The Plan covers periodontal maintenance three times a year. 

We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of periodontal maintenance have been met. Evidence was provided to show that D4910 was provided on January 19, 2021, and May 11, 2021. Therefore, we decided that the Plan has to pay for periodontal maintenance (D4910) provided by a participating provider on September 28, 2021.

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: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapeutic activities provided on August 20, 2021.  You asked the Plan to pay for therapeutic activities. You say that the physical therapy service was necessary to improve your medical condition. The Plan denied your request. The Plan says outpatient physical therapy requires prior authorization and there is no authorization on file for the date of service of August 20, 2021.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  We looked at the file and Medicare rules. The file shows that outpatient physical therapy requires prior authorization and there is no authorization on file. Based on this information, we decided that Medicare rules for coverage of therapeutic activities have not been met. Therefore, we decided that the Plan does not have to pay for therapeutic activities provided on August 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost sharing amount for the outpatient services provided on August 11, 2021.  You asked the Plan to waive the cost sharing amount for the outpatient services. You say that all of the other copay charges have been waived. You say that they were related to the coronavirus. You also say that this should be waived too. The Plan denied your request. The Plan says the claim was processed 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). The enrollee's contract with the Plan clearly says that enrollees must pay $45 copayment for a specialist visit under Outpatient diagnostic tests, therapeutic services and supplies.   The enrollee has been asked to pay $45 copayment for the outpatient services. The outpatient services fall within the specialist visit under Outpatient diagnostic tests, therapeutic services and supplies benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost sharing amount for the outpatient services provided on August 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services received on July 23, 2021.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the appropriate modifier was not billed.  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, we have confirmed that code 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services received on July 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the cost-sharing for a specialist office visit provided on September 8, 2021.  You asked the Plan to waive the cost-sharing for the specialist office visit. You say that the services should be covered as they were a follow up The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services 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 $45 copayment for Physician/Practitioner services, including doctor's office visits.     You have been asked to pay a $45 copayment for a specialist office visit. Based on your contract with the Plan, follow-up services are not fully covered after the global period has ended, these services are outside of the 92 global period and are ineligible to be covered in full. 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 cost-sharing for a specialist office visit provided on September 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a comprehensive eye examination provided on September 13, 2021.  You asked the Plan to waive the copayment for the comprehensive eye examination. You say that this was a routine annual visit, and this visit should not cost more than $15 copayment. The Plan denied your request. The Plan says a medical eye examination was rendered on September 13, 2021, and the claim processed with the correct copayment.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for Vision Care, Medicare-covered outpatient visit.   You have been asked to pay a $45 copayment for the comprehensive eye examination. The comprehensive eye examination falls within the Vision Care, Medicare-covered outpatient visit 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 comprehensive eye examination provided on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the amalgam (D2140) provided on October 5, 2021.

You asked the Plan to pay for the amalgam. You say that the Plan took your benefits from your old plan to max out all your benefits under your new plan which was never explained to you. You also say that you were told that your new dental plan, effective October 1, 2021, would be $1,000. The Plan denied your request. The Plan says you have met the annual benefit maximum.

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 Plan offers a $1,000 annual dental benefit maximum. The record shows that you met the annual maximum benefit on September 14, 2021 and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the amalgam (D2140) provided on October 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Segmented, calibrated pneumatic compression device (PCD) (E0652, E0656, E0667).  You asked the Plan to pre-approve a pneumatic compression device. You say that the items are medically necessary. The Plan denied your request. The Plan says the enrollee does not have a diagnosis of lymphedema onto the chest, trunk or abdomen.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pre-approve a Segmented, calibrated pneumatic compression device (PCD) (E0652, E0656, E0667).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Ondansetron.  You asked the Plan to pre-approve Ondansetron. You say that this is medically necessary. The Plan denied your request. The Plan says coverage of this medication is the responsibility of your prescription drug plan.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Ondansetron.   Benefits for Ondansetron 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: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to waive the 20% coinsurance for a part B drug injection, onabotulinumtoxina, provided on August 30, 2021.  

You asked the Plan to waive the 20% coinsurance for the part B drug injection. The Plan denied your request. The Plan says your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B-covered drugs. These are drugs that usually aren't self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services.  

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 the part B drug injection. The part B drug injection 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 20% coinsurance for a part B drug injection, onabotulinumtoxina, provided on August 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a visual field examination provided on June 11, 2021.

You asked the Plan to waive the copayment for a visual field examination. You say that there was no doctor involvement and that similar occurrences in the past have not assessed a copayment. The Plan denied your request. The Plan says the cost-share was applied correctly as outlined in the member's benefits in the 2021 Evidence of Coverage.

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 $25 copayment for Vision Care, Medicare-covered exam. 

You have been asked to pay a $25 copayment for a visual field examination. The visual field examination falls within the Vision Care, Medicare-covered exam 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 visual field examination provided on June 11, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eliquis 5 mg tablet.  You asked the Plan to pre-approve Eliquis. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis 5 mg tablet.   Benefits for Eliquis may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.