Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on June 30, 2021.
You asked the Plan to pay for ophthalmological services. The Plan denied your request. The Plan says this Plan
does not have out-of-network vision benefit coverage.
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision 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 ophthalmological services were not provided
by the Plan's vision provider. Based on this information, we decided that the Plan's rules for coverage of
ophthalmological services have not been met. Therefore, we decided that the Plan does not have to pay for
ophthalmological services provided on June 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the urine PCR testing provided on September 24, 2021.  

You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not medically necessary.  

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that PCR amplification techniques raise considerable concerns regarding contamination from one specimen to another, creating the potential for false-positive results. The clinical interpretation of PCR results may also be challenging. Amplification of organisms representing latent infection or colonization cannot be distinguished from active, clinically significant infections. Additionally, PCR may amplify fragments of nucleic acids, representing dead microorganisms, thus further clouding the clinical interpretation. Finally, specificities, sensitivities, and positive and negative predictive values of PCR have not been reported in large groups of patients for many of the microorganisms.  

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 testing have not been met. Therefore, we decided that the Plan does not have to pay for the urine PCR testing provided on September 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for transportation provided by the bus service from
July 10, 2021, through July 11, 2021.
You asked the Plan to reimburse you for transportation provided by the bus service. You say that you were
discharged from a facility for a procedure and left out in the cold at night and you had no other way to get
home, which was seven hours away. The Plan denied your request. The Plan says There was no indication on
that this would be a covered service or that the member would receive reimbursement. This is not a covered
service under the member's Plan.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this
case.
We looked at your request, the records in the case file, and the rule. The file shows that the transportation was
not provided under the Plan's supplemental routine transportation benefit. Therefore, we decided that the Plan
does not have to reimburse you for transportation provided by the bus service from July 10, 2021, through
July 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiology services provided on August 6,
2021.
You asked the Plan to waive the copayment for the radiology services. You say that the copayment was billed
wrong because of a prior procedure. The Plan denied your request. The Plan says the proper copayment 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 $45
copayment for IN-Network basic radiological services. The amount allowed for services was $18.51 which is
less than the copayment amount of $45.
You have been asked to pay a $18.51 copayment for radiology services. Radiology services falls within the INNetwork
Outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you
have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a
contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan
does not have to waive the copayment for radiology services provided on August 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for DME provided on July 26, 2021.
You asked the Plan to waive the deductible for DME. You say that you were told that since your deductible had been met, the charges would likely be covered. You feel that the provider is charging too much. 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 $300 deductible which applies to DME and related supplies. Your contract with the Plan also clearly says that once the $300 deductible has been met, enrollee's must pay 20% coinsurance for DME and related supplies. You received DME on July 26, 2021. The record shows that you had only paid $152.80 toward the $300 deducible prior to receiving the services. Therefore, you are responsible to pay the remaining deductible balance of $147.20. Now that the deductible has been met, you are also responsible to pay 20% coinsurance on the difference between the allowed amount and the amount that applied toward the deductible. $259.89
(allowed amount) - $147.20 (deductible amount) = $112.69 and 20% of that is $22.54. The total amount you owe is: $169.74. The item or service you asked the Plan to waive the deductible for falls within the benefit category DME and related supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $300 deductible which applies to DME and related supplies. This cost sharing is a contractual obligation that had not been met at the time DME was received on July 26, 2021. Therefore, we decided that the Plan does not have to waive the deductible for DME provided on July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 15, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the primary insurer must be billed first.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the services provided on February 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on September 10, 2021.  You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says the ambulance transport was not medically necessary.  Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules.   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 pay for ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary. Our physician reviewer found that the documentation did not support that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee. The documentation did not support that the enrollee needed the expertise, services, lifesaving and life-sustaining equipment that only a fully equipped ambulance can provide for safe transport. The documentation did not support that the ambulance transport was medically reasonable or necessary 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 ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport (A0428, A0425) provided on September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on September 20, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a domiciliary or rest home visit. You say that authorization was not obtained prior to seeing this patient since it is the nursing facility's responsibility to get authorizations for their patients. You also say that it was medically necessary for the patient to receive the treatment by this provider. The Plan denied your request. The Plan says this provider is not a network provider with the Plan. The Plan also says that they have also determined that these services are not urgent or emergent, nor were they 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 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 a domiciliary or rest home visit (99336) provided on September 20, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on October 20, 2021.
You asked the Plan to pay for the topical application of fluoride varnish. You say that your Evidence of Coverage says that your dental plan covers one fluoride treatment per year. You also say that you do not understand why you received a letter saying this service is not covered. The Plan denied your request. The Plan says this service is not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. The only type of topical application of fluoride that is covered under your plan is topical application of fluoride, excluding varnish (D1208). You received a topical application of fluoride varnish (D1206) which is not covered under your plan. Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 21, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were 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 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 on June 21, 2021.
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
August 8, 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 August
8, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.

You asked the Plan to pre-approve Entyvio. You say that the requested Entyvio is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail Remicade, Inflectra, or Infliximab AND has tried or cannot use Stelara.

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 Entyvio. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records provided the enrollee has not tried and failed the required drug(s). There is no indication that the Plan's required drug(s) 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 Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  You asked the Plan to pre-approve the Intracept procedure. You say that the requested Intracept procedure is medically necessary. The Plan denied your request. The Plan says the requested Intracept procedure is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Intracept procedure. Our reviewer says that the requested Intracept procedure is not medically necessary. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy. The Intracept procedure is not medically necessary at this time.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for nursing facility care (99309) provided on November 21, 2019.  

You asked the Plan to pay for nursing facility care. You say that this was originally filed timely. The Plan denied your request. The Plan says this was filed more than a year after the service.  

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.  

The record shows that a claim for nursing facility care was not filed until June 23, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for nursing facility care (99309) provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the shingles vaccine provided on June 21, 2021.
You asked the Plan to pay for the vaccine. The Plan denied your request. The Plan says this is not a covered
benefit.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The
Plan follows the same rules.
The records do not show that the enrollee has been injured or directly exposed to any illness related to the
vaccine. Therefore, we decided that the Plan does not have to pay for the shingles vaccine provided on June 21,
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an attendant control (E2331) and cup holder (K0108).  You asked the Plan to pre-approve an attendant control (E2331) and cup holder (K0108). You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the records show that your current wheelchair includes a beneficiary-operated joystick. Medicare says an attendant control cannot be covered in addition to a beneficiary-operated joystick. The cup holder is a convenience item and is not covered by Medicare or the Plan.  The Plan must follow Medicare rules. Medicare rules say that if an attendant control (E2331) is provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. The rules also say that for equipment to be covered, it must primarily serve a medical purpose. The file shows that your current wheelchair includes a beneficiary-operated joystick. Furthermore, the requested cup holder does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve an attendant control (E2331) and cup holder (K0108).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for emergency care provided on August 13,
2021.

You asked the Plan to waive the copayment for the emergency care. You say that the hospital discharged you
because they were too busy, and you returned the next week. The Plan denied your request. The Plan says the
proper copayment 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 $120
copayment for emergency care.

You have been asked to pay a $120 copayment for the emergency care. Emergency care falls 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 emergency care
provided on August 13, 2021.

Your complaint about your experience with this provider 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: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for acupuncture services provided from August 27, 2021, through September 10, 2021.  You asked the Plan to pay for acupuncture services. The Plan denied your request. The Plan says you are covered for up to 12 routine acupuncture visits. The Plan says our records indicate that you have exhausted your benefits for routine acupuncture as of August 3, 2021.  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case.   We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, the file shows that you have exhausted your benefit for routine acupuncture services as of August 3, 2021. Therefore, we decided that the Plan does not have to pay for acupuncture services provided from August 27, 2021, through September 10, 2021.