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

We decided that the Plan does not have to pre-approve Remicade, 100 mg.
You asked the Plan to pre-approve Remicade. You say that the biosimilar drugs are not approved for the
enrollee's condition. The Plan denied your request. The Plan says the enrollee has not tried the preferred drugs,
Inflectra and Renflexis.
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 Remicade. Our reviewer says that Remidcade is not medically necessary. Our physician reviewer found the enrollee's Plan requires a trial of Inflectra and Renflexis before they will approve the requested drug. The reviewer found that the enrollee has not tried and failed the required drugs. The reviewer also found there is no documentation provided indicating that the plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Remicade have not been met. Specifically, the file shows that the enrollee has not tried and failed the required drugs. Therefore, we decided that the Plan does not have to pre-approve Remicade, 100 mg.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an abdominal ultrasound (76700) provided on May 12, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an abdominal ultrasound. You say that you would like the medical records to be reviewed and the claim to be reprocessed and paid. The Plan denied your request. The Plan says the provider is not an in-network provider. The services were 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 an abdominal ultrasound (76700) provided on May 12, 2021, 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 cystourethroscopy (52000) provided February 8, 2021.

You asked the Plan to waive the copayment for the cystoscopy. You say that the provider told you this charge should be covered by the health plan. The Plan denied your request. The Plan says the copayment has been adjusted from the original claim. The current copayment has been applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $45 copayment for services rendered by a physician specialist in an outpatient hospital setting.

You have been asked to pay a $45 copayment for the cystoscopy. The requested cystoscopy, performed by a urologist, falls within the Outpatient hospital 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 cystourethroscopy (52000) provided February 8, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayments for the posterior tibial nerve stimulation
treatments you received at an outpatient hospital facility between April 20, 2021, and May 25, 2021.
You asked the Plan to reduce the copayments for the posterior tibial nerve stimulation treatments. You say that
you thought you were just received acupuncture services that only have a $35 copayment per session. You
stated that, had you known of the cost of these services, you would have cancelled the appointments. 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 $260
copayment for surgery or other services at an outpatient hospital facility.
You have been asked to pay a $260 copayment for the posterior tibial nerve stimulation treatments. The
posterior tibial nerve stimulation treatments fall within the surgery or other services at an outpatient hospital
facility 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 reduce the copayments for the posterior tibial nerve
stimulation treatments you received at an outpatient hospital facility between April 20, 2021, and May 25,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the facet joint services.
You asked the Plan to pre-approve the requested services. You say that the enrollee had at least 50% of consistent reduction in pain for at least 6 months. The Plan denied your request. The Plan says there is no clinical information documentation medical necessity.
The Plan follows Medicare rules. Medicare rules say that facet joint interventions are only covered under certain medical indications. 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 requested services. Our physician reviewer found that the enrollee has chronic axial neck pain that has been previously successfully treated with radiofrequency ablation (RFA) at 3 levels. The enrollee has taken Advil, Voltaren gel and Cyclobenzaprine for pain. The records show the physician wants to repeat the diagnostic medial branch blocks (MBBS) at those levels. The standard of care algorithm is to repeat the RFA, not to repeat diagnostic MBBs. The coverage criteria also limits the procedure to 2 levels in a session. Therefore, the request is deemed 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve the facet joint services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the therapeutic exercises (97110), neuromuscular reeducation (97112), physical therapy evaluation (97161), electrical stimulation (G0283), and gait training therapy (97116) provided from June 23, 2021, through July 8, 2021.

You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to 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 $30 copayment for each visit for Medicare-covered occupational therapy, physical and/or speech and language therapy.

You have been asked to pay $180 ($30 copayment x 6) for the physical therapy visits provided. 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 therapeutic exercises (97110), neuromuscular reeducation (97112), physical therapy evaluation (97161), electrical stimulation (G0283), and gait training therapy (97116) provided from June 23, 2021, through July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a partial upper denture (D5211).

You asked the Plan to pre-approve the dental item. You say that this service is medically necessary. The Plan
denied your request. The Plan says the intended partial denture is only replacing one second molar and
therefore is not medically necessary.

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 the dental
item when the services are medically necessary and reasonable.

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 dental item. Our reviewer says that
the requested partial denture is not medically necessary. Our physician reviewer found provided documentation
indicates that the enrollee's remaining upper arch is intact or has been restored with fixed bridgework. The
replacement of a single tooth has questionable value especially where there is minimal occlusal functioning.
The reviewer found that a one tooth partial denture replacing a second molar does not meet the criteria of being
"one that meets, but does not exceed, the patient's medical need; and at least as beneficial as an existing and
available medically appropriate alternative." The reviewer found that the requested appliance would not meet
the enrollee's need and would likely be detrimental to the remaining teeth. Therefore, the reviewer found that
the requested upper partial denture is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
the Plan's rules for coverage of the dental item have not been met. Specifically, the file shows that the requested
appliance would not meet the enrollee's need and would likely be detrimental to the remaining teeth. Therefore,
we decided that the Plan does not have to pre-approve a partial upper denture (D5211).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for outpatient chemotherapy provided on June 23, 2021.
You asked the Plan to waive the coinsurance for outpatient chemotherapy. You say that you were told you would only have a $30 copay for the procedure. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for Outpatient Hospital Services, Medicare Part B drugs. You have been asked to pay 20% coinsurance for outpatient chemotherapy. The outpatient chemotherapy falls within the Outpatient Hospital 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 coinsurance for outpatient chemotherapy provided on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for evaluation and management services provided on April 24, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the services provided. You say that treatment was rendered in good faith. The Plan denied your request. The Plan says out-of-network providers must obtain prior authorization for all services rendered.

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 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 evaluation and management services provided on April 24, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the portable ventilator to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the portable ventilator. You say that the insurance previously approved authorization with the same plan and benefits with back-date showing the provider was out-of-network at that time as well. The Plan denied your request. The Plan says the provider is out-of-network.

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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. The records provided for review do not show that the service at issue is urgent or emergent.

Therefore, we decided that the Plan does not have to pre-approve the portable ventilator to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care provided on June 30, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the wound care. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was 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. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for wound care provided on June 30, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lazy boy recliner chair (E1399).
You asked the Plan to pre-approve a lazy boy recliner chair. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal 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 a lazy boy recliner chair (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for complete dentures (D5120 and D5110), provided on February 22, 2021.
You asked the Plan to pay for complete dentures. You say that the services should be covered. The Plan denied your request. The Plan says you have exceeded your maximum allowance for supplemental dental services.
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. Specifically, the Plan has a &1000 maximum allowance, you exceeded the allowance and are responsible for the difference. Therefore, we decided that the Plan does not have to pay for complete dentures (D5120 and D5110), provided on February 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the urgent care office visit (99213)
provided on May 13, 2021.

You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service 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 $10
copayment for each covered office visit to your primary care provider for urgently needed services. You also
pay a $45 copayment for each covered office visit to other providers for urgently needed services.

You have been asked to pay a $45 copayment for the urgent care office visit rendered by a provider that is not
your primary care physician. 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 adjust the copayment for the urgent care office visit
(99213) provided on May 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
You asked the Plan to pre-approve the maxillary partial denture and mandibular partial denture. You say that you cannot regain proper function without teeth. The Plan denied your request. The Plan says these services exceed the maximum counts allowed per period.
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, maxillary partial denture (D5213) and mandibular partial denture (D5214) are each limited to one procedure every five plan years. The record shows that you received a maxillary partial denture (D5213) and a mandibular partial denture (D5214) on November 26, 2019 and your maxillary partial denture (D5213) and mandibular partial denture (D5214) benefits have been exhausted. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital services provided June 4, 2021, to June 5, 2021.
You asked the Plan to pay for inpatient hospital services. You say that these services were medically necessary. The Plan denied your request. The Plan says that the claim has denied as the bill type is a nonpayment claim.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. The enrollee was referred for inpatient hospital services by a contract provider. The file does not show that the plan provided notice that inpatient hospital services would not be covered. Under Medicare rules, this means inpatient hospital services is considered approved by the plan. Therefore, we decided that the Plan has to pay for inpatient hospital services provided June 4, 2021, to June 5, 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions (37766) provided on September 14, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service 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 $425 copayment for outpatient hospital surgery. You have been asked to pay a $425 copayment for the outpatient hospital surgery provided. 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 stab phlebectomy of varicose veins, 1 extremity; more than 20 incisions (37766) provided on September 14, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the resin (D2332), provided on June 16, 2021.
You asked the Plan to pay for the resin. You say that the services should be covered. The Plan denied your request. The Plan says you received the service from a provider that does not participate with this 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. Specifically, you received the service from a provider that does not participate with your Plan. This means you are responsible for the full cost of the service. Therefore, we decided that the Plan does not have to pay for the resin (D2332), provided on June 16, 2021.