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

We decided that the Plan does not have to pay for an eye refraction provided on September 14, 2021.

You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says eye refractions are only covered by your plan if performed by a participating provider and performed as a routine screening per your 2021 Evidence of Coverage.

Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.

We looked at the file and the Medicare rules. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury. Therefore, we decided that the Plan does not have to pay for an eye refraction provided on September 14, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio (J3380).
You asked the Plan to pre-approve Entyvio. You say that you would like to make an expedited appeal because you cannot wait for the standard turnaround time. The Plan denied your request. The Plan says you do not have any stated contraindications to the preferred products. The Plan also says that you have not tried any of the preferred agents, and the provider does not provide a rationale for use of the non-preferred product for safety or efficacy.
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 Entyvio (J3380) is not medically reasonable and necessary. Our physician reviewer found relative to initiation of biologic therapy, specialty society guidelines identify no advantage of induction therapy with Entyvio in biologically-naive ulcerative colitis patients compared with Plan formulary alternatives, such as anti-Tumor Necrosis Factors like Humira. Our physician also found that the available record fails to provide current objective evidence for moderate to severely active ulcerative colitis, inadequate response with or lost response to the Plan-preferred alternatives, nor demonstrated dependence on corticosteroids. In fact, the provider documentation supports significant clinical response to non-biologic treatment as well as the appellant's reluctance to initiate Entyvio. 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 (J3380).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment and deductible for observation services,
physical therapy and occupational therapy provided from December 16, 2020, to December 18, 2020.
You asked the Plan to waive this cost share for the enrollee. You say that you do not believe this cost share is
correct. The Plan denied your request. The Plan says this cost share was charged based on the Plan contract
agreement. We overturned the Plans denial as the correct Plan contract was not submitted with the case
file. The Plan requested a reopen and submitted the required Plan contract for 2020.
The Plan is correct in this case. The rules say a plan must disclose to its enrollees in clear, accurate terms all
cost sharing information (such as copayments, deductibles, and coinsurance). The enrollee's contract with the
Plan clearly says that enrollees must pay 20% coinsurance for out of network outpatient services after the
deductible is met. The enrollee has been asked to pay the correct amount based on the contract with the Plan.
This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore,
we decided that the Plan does not have to waive the copayment and deductible for observation services,
physical therapy and occupational therapy provided from December 16, 2020, to December 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of a CPAP.
You asked the Plan to pre-approve continued coverage of CPAP. You say that continued coverage of a CPAP
machine is medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria are
not met. We overturned the Plans denial. The Plan requested a reopen and stated that we did not
apply the correct criteria.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare only provides continued
coverage for a CPAP device when the compliance report shows the enrollee adhered to the usage expectation.
Medical necessity is not of issue when the enrollee is clearly not compliant with usage and there is no specific
medical reason compliance was not obtainable. The compliance report shows the enrollee used this device two
out of 30 nights. Neither of those nights were for a period greater than four hours. The total usage was two
hours for an entire month. The guidelines require the device be used four hours per night for continued
coverage. Medicare rules for coverage of continued coverage of CPAP have not been met. Therefore, we
decided that the Plan does not have to provide continued coverage of a CPAP.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
March 9, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that it was your 
understanding that you would not be charged for any coronavirus vaccine related charges. The Plan denied 
your request. The Plan says you have been charged 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 $200 
copayment for each date of service for ground transportation. 

You have been asked to pay a $200 copayment for the ambulance transportation. Please note that there are no 
cost-share waivers in effect for coronavirus vaccine related expenses. The ambulance transportation falls within 
the Ambulance 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 ambulance 
transportation provided on March 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the wound care services provided on May 
4, 2021 and May 11, 2021.

You asked the Plan to waive the copayment for the wound care services. You say that this was the same wound 
they treated you for in April and you don't understand why you're paying another $125 copayment. The Plan 
denied your request. The Plan says the copayment 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 $125 
copayment for Medicare-covered surgery or other services provided to you at an ambulatory surgical center, 
including but not limited to hospital or other facility charges and physician or surgical charges. 

You have been asked to pay a $125 copayment for the wound care services. Wound care services fall 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 wound care 
services provided on May 4, 2021 and May 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).
You asked the Plan to pre-approve an Intracept procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.
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 an Intracept procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show it is safe and effective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure (22899, C9752).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for GeneSight testing provided on February 12, 2021.

You asked the Plan to pay for GeneSight testing. You say that no basis exists for the Plan to deny coverage for 
this testing. The Plan denied your request. The Plan says that the denial of payment for this testing is correct, 
because this test is not covered, the claim did not include the DEX Z-Code required by billing rules, has not 
shown to be useful, and is not considered medically necessary and appropriate.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 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. Medicare rules say that pharmacogenomics tests should be billed with the appropriate Current 
Procedural Terminology (CPT) code, DEX Z-Code, and International Classification of Diseases 10 Clinical 
Modification (ICD-10-CM) code.

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request.

The Plan did not specify whether the ordering physician was in-network or out-of-network with the Plan. The 
documentation submitted does not include prior notice from the Plan that this testing would not be covered. 
Without this information, we cannot determine whether the lab order made constituted plan-directed care. 
Furthermore, the Plan did not submit a copy of the original claim form that you billed to the Plan. Without the 
original claim form, we cannot determine whether this testing was billed in accordance with Medicare billing 
rules. Therefore, the Plan has not shown that its decision to deny payment for this testing is correct or justified 
according to Medicare rules. Therefore, we decided that the Plan has to pay for GeneSight testing provided on 
February 12, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on August 3, 2021.

You asked the Plan to pay for the services provided. You say that the provider determined the enrollee required 
testing. The Plan denied your request. The Plan says the testing is considered unproven.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered.

The file shows that urinary tract infection panel testing was provided. We looked at the file and the rules. A 
bacterial urine culture is performed for a presumed urinary tract injection. The records provided do not show 
how the panel testing will impact clinical management over the standard of care. The services provided were 
requested for screening purposes. Medicare does not cover this testing for screening purposes. Therefore, we 
decided that the Plan does not have to pay for the lab services provided on August 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on April 12, 2021.

You asked the Plan to pay for the services provided. You say that the lab is licensed to perform high 
complexity tests. The Plan denied your request. The Plan says the place of service must reflect where the 
specimen was obtained.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code.

We looked at the file and the rules. The claim lists a place of service as an independent laboratory. The records 
do not indicate that the specimen was obtained at an independent laboratory. Based on this information, we 
decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the drug testing services provided on April 12, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on August 27, 2021.
You asked the Plan to waive the copayment for an ultrasound. You say that you disagree with the Plan paying $0 toward the claim. 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 $110 copayment for radiological diagnostic services. You have been asked to pay the allowed amount of $109.29, which is less than the $110 copayment for an ultrasound. An ultrasound falls within the 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 an ultrasound provided on August 27, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay provided from June 17, 2021, to
June 28, 2021.

You asked the Plan to waive the copayment for a SNF stay. You say that you feel that you were not receiving
adequate rehabilitation at this facility. 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 $0
copayment for days 1-20 and a $184 copayment for days 21-48 for SNF care.

The record shows that you had a SNF stay from June 17, 2021, to June 28, 2021. The record shows that you
had a previous SNF stay for a total of 21 days. Therefore, you are responsible to pay a $184 copayment for
days 22-32 (June 17, 2021, to June 27, 2021). The total amount you owe is: $184 (copayment) x 11 (SNF days)
= $2,024.

You have been asked to pay the total copayment amount of $2,024 for a SNF stay. A SNF stay falls within the
SNF 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 a SNF stay provided from
June 17, 2021, to June 28, 2021.

Your quality-of-care concerns have been handled separately by the health plan. Medicare does not permit
the Qualified Independent Contractor to make a decision on this type of complaint.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the repair of an inguinal hernia provided on September 1, 2021.

You asked the Plan to waive the copayment for the repair of an inguinal hernia. You say that you were told that you were having the procedure done at a surgery center and you should only owe a $75 copayment. 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 $75 copayment for surgery or other services when provided at an ambulatory surgical center and a $175 copayment when provided at an outpatient hospital facility. 

The medical records show that you received the repair of an inguinal hernia at an outpatient hospital facility on September 1, 2021. Therefore, you are responsible to pay the $175 copayment.

You have been asked to pay a $175 copayment for the repair of an inguinal hernia. The repair of an inguinal hernia 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 repair of an inguinal hernia provided on September 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.
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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. While the enrollee may benefit from physical therapy (PT), and occupational therapy (OT), her rehab needs can be safely provided in an alternate and low intensity setting such as in a skilled nursing facility or in home with PT, OT, and wound care 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two prefabricated abutments (D6056 x2) provided on August 31, 2021.

You asked the Plan to pay for the prefabricated abutments. You say that you thought your insurance would pay some of this dental bill. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 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. Therefore, we decided that the Plan does not have to pay for the two prefabricated abutments (D6056 x2) provided on August 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).
You asked the Plan to pre-approve the insertion of stabilization device (22869 and 22870). You say that the patient has failed several months of conservative approaches to treatment. You say that this treatment is considered safe and effective and should be approved. The Plan denied your request. The Plan says there are not enough studies to show Vertiflex Superion is safe and effective to treat back pain.
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 insertion of stabilization device (22869 and 22870). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the Vertiflex device is experimental. Our reviewer says that more research is needed to show safety and efficacy.
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 insertion of stabilization device (22869 and 22870) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22869 and 22870).