Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayments for telehealth visits with a specialist provided on May 18, 2021, and June 4, 2021.
You asked the Plan to waive the copayments for telehealth visits with a specialist. You say that you were not informed that you would owe a copayment for phone visits and disagree with the charges. The Plan denied your request. The Plan says that 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 does not say in clear and accurate terms how much you should expect to pay for telehealth services provided by a specialist. We looked at your contract with the Plan. We did not see where the contract says enrollees must pay a $30 copayment for telehealth services provided by a specialist. The Plan contract does not clearly say how much enrollees must pay for telehealth services provided by a specialist. This means that the Plan did not follow Medicare rules for disclosure of cost sharing information. Therefore, we decided that the Plan has to waive the copayments for telehealth visits with a specialist provided on May 18, 2021, and June 4, 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the limited oral evaluation (D0140) and extractions (D7140 x 2) provided from January 14, 2021, to February 22, 2021.  You asked the Plan to pay for the dental services. You say that this dentist has been in network since the day she started. You say that other dates of service from this provider have been paid in full. You also say that these services should be covered. The Plan denied your request. The Plan says the services in this case were paid at the allowable rate. The Plan says that the provider in this case was out of network on the dates of service in this case. The Plan says that the provider did not become in network with the plan until March 31, 2021, after the dates of service in this case. The Plan also says that out of network providers may bill you for any amount greater than what the plan pays.  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 and the services are listed as covered, out of network dentists may bill you for any amount greater than what the Plan pays. The record shows that the Plan paid the allowed amount of $33 towards the $95 that was billed for the limited oral evaluation. $95 - $33 = $62. The record shows that the Plan paid 50%, or $56, of the allowed amount of $112 towards the $398 that was billed for the extractions. $398 - $56 = $342. As such, the member responsibility of $342 + $62 = $ 404 remains. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) and extractions (D7140 x 2) provided from January 14, 2021, to February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for subsequent hospital care provided on June 9, 2021.
You asked the Plan to waive the deductible for subsequent hospital care. You say that you disagree with the charges because the doctor's round should be covered in the inpatient hospital stay. 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. Your contract with the Plan says that there is a $500 deductible which applies to inpatient hospital care. You received subsequent hospital care on June 9, 2021. The record shows that you paid $408.09 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay $46.32.
The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time subsequent hospital care was received on June 9, 2021. Therefore, we decided that the Plan does not have to waive the deductible for subsequent hospital care provided on June 9, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray of the hand you had at an outpatient hospital facility on July 25, 2021.
You asked the Plan to waive the copayment for the x-ray. You say that there is no urgent care open on Sundays in your area. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this service ($72.48) 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 $100 copayment for x-rays in an outpatient hospital facility. You have been asked to pay a $100 copayment for the x-ray. This copayment applies regardless of the reason
why you went to the hospital. 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 x-ray of the hand you had at an outpatient hospital facility on July 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve diabetic shoes and inserts to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. You say that the enrollee has back problems and nerve damage. The Plan denied your request. The Plan says there are in-network providers available.  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 OON services. Therefore, we decided that the Plan does not have to pre-approve diabetic shoes and inserts to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ultrasound of the head and neck you
had on July 30, 2021.
You asked the Plan to waive the copayment for the ultrasound. You say that you do not understand why the
Plan didn't pay anything towards this necessary test. The Plan denied your request. The Plan says you were
charged this copayment correctly. The Plan says that because the allowed amount for this test ($94.38) 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 $105
copayment for radiological diagnostic services.
You have been asked to pay a $105 copayment for the ultrasound. The ultrasound falls within the radiological
diagnostic 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 the ultrasound of the head and neck you had on July 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from November 24, 2021, forward.
You asked the Plan to pre-approve inpatient psychiatric care from November 24, 2021, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care from November 24, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of November 24, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond November 24, 2021, as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from November 24, 2021, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from November 24, 2021, forward.
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 the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
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. Our physician reviewer found based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. 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.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve OON services. You say that you would like to have a second opinion. The Plan denied your request. The Plan says there are contracted providers available.  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 OON services. Therefore, we decided that the Plan does not have to pre-approve oncology services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an extracapsular cataract removal with insertion of intraocular lens prosthesis (66984) rendered on July 7, 2021.
You asked the Plan to waive the copayment for extracapsular cataract removal with insertion of intraocular lens prosthesis. You say that you were charged $995 on the day of your procedure and then was billed $275. You also say that you were told it is the copayment and that if the charge was the copayment, why were you then charged $995 on the day of your surgery. The Plan denied your request. The Plan says you were 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 $275 copayment for out-of-network ambulatory surgical centers.
You have been asked to pay a $275 copayment for extracapsular cataract removal with insertion of intraocular lens prosthesis. An extracapsular cataract removal with insertion of intraocular lens prosthesis falls within the outpatient surgery, including services provided at outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an extracapsular cataract removal with insertion of intraocular lens prosthesis (66984) rendered on July 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia (denosumab).
You asked the Plan to pre-approve Prolia. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not being requested for a medically-accepted indication.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.
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 Prolia. Our reviewer says that the enrollee does not meet the criteria for the requested use of Prolia. Our physician reviewer found the enrollee has a diagnosis of hormone sensitive metastatic prostate cancer. The Food & Drug Administration (FDA) has not stated that Prolia is approved for this diagnosis. The requested use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia (denosumab).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for the periodic exam (D0120) and cleaning (D1110) provided on March 25, 2021.
You asked the Plan to pay an additional amount for the dental services. You say that you should be reimbursed 50% of the out of pocket cost for these services. The Plan denied your request. The Plan says routine oral exams and cleanings have a 50% coinsurance when you receive these service out of network. The Plan says that the services were paid by your primary insurance beyond what your secondary insurance would have paid. The Plan also says that no additional payment can be made.
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 and the services are listed as covered, the payment made by your primary insurance exceeds the payment that would have been made by your secondary insurance. As a result, there will be no additional payment made by your secondary insurance. Therefore, we decided that the Plan does not have to pay an additional amount for the periodic exam (D0120) and cleaning (D1110) provided on March 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for subsequent hospital care provided on June 8, 2021.
You asked the Plan to waive the deductible for subsequent hospital care. You say that the doctor was doing their rounds during a hospital stay and you disagree with 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. Your contract with the Plan says that there is a $500 deductible which applies to inpatient hospital care. You received subsequent hospital care on June 8, 2021. The record shows that you had only paid $389.60 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $71.44.
The item or service you asked the Plan to waive the deductible for falls within the benefit category inpatient hospital care. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time subsequent hospital care was received on June 8, 2021. Therefore, we decided that the Plan does not have to waive the deductible for subsequent hospital care provided on June 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed.
You asked the Plan to pre-approve total electric hospital bed. You say that you are very hurt in your bed and need this bed. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because a total electric hospital bed is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered because the height adjustment feature is a convenience feature. We looked at the file and Medicare rules. The requested total electric hospital bed is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of total electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed.
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 the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
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. Our physician reviewer found based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the
enrollee requires that are not already available and covered at the current facility. 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.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Keytruda infusions (J9271), 2 mg/kg every 21 days for 6 months.  You asked the Plan to pre-approve Keytruda infusions. You say that the requested infusions are medically necessary. The Plan denied your request. The Plan says continued treatment with Keytruda is not recommended once your cancer has progressed or after two years of therapy.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Keytruda infusions. Our reviewer says that Keytruda infusions are not medically necessary. Our physician reviewer found the provided documentation indicates that the enrollee has been on the requested treatment for over 2 years and has had disease progression during that time. The Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's condition. The Medicare approved cancer drug compendia do not contain a supportive citation for the use of the requested drug in the enrollee's clinical situation. The reviewer found that no literature from Medicare approved cancer journals were submitted for review. Therefore, the reviewer found that the requested Keytruda infusions are 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 Keytruda infusions have not been met. Specifically, the file does not show that the requested drug is approved by the Food and Drug administration (FDA) for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve Keytruda infusions (J9271), 2 mg/kg every 21 days for 6 months.