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

We decided that the Plan does not have to pre-approve the Vertiflex procedure for the enrollee.
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertilfex device is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on June 6, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 on June 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the medical eye exam and the ophthalmic imaging services you received on July 14, 2021.
You asked the Plan to waive the copayments for the medical eye exam and the ophthalmic imaging services. You say that the eye exam you had should have no copayment. The Plan denied your request. The Plan says you were charged these copayments 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 $25 copayment for medical eye exams and a $10 copayment for diagnostic tests.
You have been asked to pay a $25 copayment for the medical eye exam and a $10 copayment for the ophthalmic imaging services. The records show that they eye exam you had was a medical eye exam because you were evaluated for dry eye, cataracts, and macular puckering. According to your Evidence of Coverage, only routine eye exams have no copayment. This was not a routine eye exam because of the medical condition evaluation. In addition, the ophthalmic imaging services are considered diagnostic testing, which is separately payable from the exam itself. 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 the medical eye exam and the ophthalmic imaging services you received on July 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the therapeutic phlebotomy provided on April 27, 2021.

You asked the Plan to waive the copayment for the therapeutic phlebotomy. You say that you had this same procedure in 2017 with no copayment. You would like the copayment waived. 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 $370 copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the standard $370 copayment for the therapeutic phlebotomy.

You have been asked to pay a $129.90 copayment for the therapeutic phlebotomy. The therapeutic phlebotomy falls within the "Outpatient Surgery and Other Medical 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 the therapeutic phlebotomy provided on April 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.
You asked the Plan to pre-approve these services. You say that these services are necessary to help reduce your risk of being paralyzed. The Plan denied your request. The Plan says that the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Bone marrow aspirate remains experimental for use in spine surgery as a bone graft substitute. More research is needed to show safety and efficacy. Our physician reviewer found that your condition does not meet criteria for these
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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bone marrow aspiration.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on June 23, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says based on the enrollee's hospice status at the time of service, this claim must be submitted to Original Medicare first.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician services provided to the enrollee on June 23, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. The services are therefore not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on
March 13, 2021.
You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says that you were issued payment for 1 pair of lenses and frames purchased on March 13, 2021. Therefore, the remaining claim amount of $152.80 denied correctly, as the member is responsible for the remaining cost of the vision items.
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 benefit amount for the eyeglasses, and you are responsible for the balance. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on March 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the pathology services provided on April 6, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON pathology services. You say that these services were medically necessary. The Plan denied your request. The Plan says the claim was denied due to a coding issue; however, on review it was found that these services were provided OON and ordered by an OON provider. No authorization was requested or issued 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 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 the pathology services provided on April 6, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for cataract surgery (0191T, 66984) provided on June 1, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for OON cataract surgery. You say that this was medically necessary. The Plan denied your request. The Plan says this was not authorized.

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 cataract surgery (0191T, 66984) provided on June 1, 2021, 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 a lumbar-sacral orthosis provided on May 25, 2021.

You asked the Plan to waive the coinsurance for a lumbar-sacral orthosis. You say that you did not want the device and have never used it. 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 DME and related supplies. 

The record shows that you received a lumbar-sacral orthosis on May 25, 2021. Therefore, you are responsible to pay your share of the cost-sharing charges. The total allowed amount is $837.16 and 20% of that is $167.43. 

You have been asked to pay the total coinsurance amount of $167.43 for a lumbar-sacral orthosis.

A lumbar-sacral orthosis falls within the durable medical equipment (DME) 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 a lumbar-sacral orthosis provided on May 25, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the behavioral health services provided on June 1, 2021 to June 22, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for these services. You say that you were told you could see this provider. The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 the behavioral health services provided on June 1, 2021 to June 22, 2021 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm.
You asked the Plan to pre-approve Aduhelm. You say that the requested Aduhelm is medically necessary. The Plan denied your request. The Plan says the requested Aduhelm is 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 Aduhelm. Our reviewer says that the requested Aduhelm is not medically necessary. Our physician reviewer found the enrollee was evaluated by a neurologist on October 5, 2021. The neurological examination was unremarkable, with intact attention and orientation. The enrollee answered all questions appropriately, and there was no gross cognitive impairment. A Mini-Mental State Exam (MMSE) was scored 25, which correlates with normal cognition. The listed diagnoses included Alzheimer's disease and Parkinson's disease. The enrollee was taking Aricept. Namenda was to be started. An Magnetic resonance imaging (MRI) was obtained on July 8, 2021, but the results are not available in the case file. The available clinical documentation does not support that the enrollee has a diagnosis of Alzheimer's disease with cognitive deficits that interfere with independence in everyday activities. The results of brain imaging are not available. It has not been shown that Aduhelm is at least as beneficial as existing and appropriate and available medically appropriate alternatives for this 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 Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a nasopharyngoscopy with dilation of the eustachian tube (69706).

You asked the Plan to pre-approve a nasopharyngoscopy with dilation of the eustachian tube. You say that the enrollee has failed other treatments. The Plan denied your request. The Plan says that this is experimental.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 a nasopharyngoscopy with dilation of the eustachian tube. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the records show that the enrollee has failed numerous surgical and medical therapies over many years. The enrollee had good results with a previous bilateral Eustachian tube balloon procedure. Current studies support that Eustachian tube balloon dilation can be a helpful procedure for patients with Eustachian tube dysfunction. The evidence supports that the procedure is safe and effective in this setting. 

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 nasopharyngoscopy with dilation of the eustachian tube have been met. Therefore, we decided that the Plan has to pre-approve a nasopharyngoscopy with dilation of the eustachian tube (69706).

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 waive the copayments for ambulance services and an inpatient
hospital stay provided from May 19, 2021, to May 21, 2021.
You asked the Plan to waive the copayments for ambulance services and an inpatient hospital stay. You say
that you were held against your will and should not be responsible for the charges. 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 $150
copayment for ambulance services. Your contract with the Plan also clearly says that you must pay a $180
copayment for days 1-5 for inpatient hospital care.
You received ambulance services on May 19, 2021. Therefore, you are responsible to pay the $150 copayment.
You had an inpatient hospital stay from May 19, 2021, to May 21, 2021. Therefore, you are responsible to pay
a $180 for days 1-2 (May 19, 2021, to May 20, 2021). The total amount you owe is: $180 (copayment) x 2
(inpatient days) = $360.
The total amount you owe is: $510.
You have been asked to pay the total copayment amount of $510 for ambulance services and an inpatient
hospital stay. Ambulance services fall within the ambulance services benefit category. An inpatient hospital
stay falls within the inpatient hospital 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 copayments
for ambulance services and an inpatient hospital stay provided from May 19, 2021, to May 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids (V5298) provided March 30, 2021.
You asked the Plan to pay for the hearing aids. You say that you were unaware you needed to use a specific provider. The Plan denied your request. The Plan says there is not coverage for hearing aids if they are not purchased through the specified provider.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when ordered directly from the Plan's specified hearing provider. We looked at the file and the Plan's rules. In this case hearing aids were not purchased from the Plan's specified hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing aids (V5298) provided March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit you had on June 21, 2021.

You asked the Plan to waive the copayment for the urgent care visit. You say that you went to the urgent care center on June 15, 2021, because you fell and hit the back of your head. You stated that they put eight staples in. You had to return to the urgent care center on June 21, 2021, to have the staples removed. You say that this visit should be included in the cost for the first visit. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this visit ($24.11) is less than your copayment obligation, you are responsible for the full allowed 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 $55 copayment each visit for urgent care. 

You have been asked to pay a $55 copayment each visit for the urgent care visit. This copayment applies each time you visit urgent care, regardless of the reason for the visit. 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 urgent care visit you had on June 21, 2021.