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

We decided that the Plan does not have to pre-approve intensity-modulated radiation therapy (IMRT).
You asked the Plan to pre-approve IMRT. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of authorization for this service is correct, because IMRT is not
medically necessary and 3-dimensional conformal radiation therapy would be approved instead if requested.
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 IMRT. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found when using palliative doses of radiation, it is not plausible that IMRT would afford a clinically
meaningful benefit over standard 3-dimentional (3D) conformal radiation therapy. If a complex field were
being planned that would encompass the prostate and select sites of bone metastases, IMRT could be justified
for the treatment of a complex field. However, the plan for this patient is to treat those sites separately. As
such, IMRT for palliation would not be furnished in accordance with accepted standards of medical practice
without providing a dosimetric rationale showing a plausible, clinically meaningful benefit.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IMRT have not been met. Therefore, we decided that the Plan does not have to
pre-approve intensity-modulated radiation therapy (IMRT).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 10, 2021.
You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says the $171.16 coinsurance was applied correctly to the claim. In addition, a warranty is not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The file shows that the Plan applied the correct $171.16 coinsurance to the claim and a warranty is not a covered benefit. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the telehealth services provided on January 11, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the telehealth services provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says telehealth services are not covered when provided by an out-of-network provider. The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the telehealth services provided on January 11, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a four wheeled scooter received on May 4, 2021. 
 
You asked the Plan to pay for a four wheeled scooter. You say that you called and were given three different 
names of suppliers which neither had the item you were looking for. The Plan denied your request. The Plan 
says the item received is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery. 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 care from out-of-network providers 
only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The record does not contain a valid physician order. The record shows that the Plan made several attempts to 
obtain the necessary documentation without success. In addition, 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 four wheeled scooter received on May 4, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to hold you harmless for the magnetic resonance imaging (MRI) received on June 
18, 2021 minus any cost share requirement. 
 
You asked the Plan to pay for the MRI. You say that you feel these services were necessary. The Plan denied 
your request. The Plan says that the services received were not medically necessary. 
 
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. 
 
You were referred for the MRI by a contract provider. The file does not show that the Plan provided notice that 
the MRI would not be covered. Under Medicare rules, this means the MRI is considered approved by the Plan. 
Therefore, we decided that the Plan has to hold you harmless for the magnetic resonance imaging (MRI) 
received on June 18, 2021 minus any cost share requirement.  
 
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 lab services (81479) provided May 18, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Medicare covers SelectMDx in males with previous negative prostate biopsy who are being considered for repeat biopsy. We looked at the file and Medicare rules. The record does not show a previous prostate biopsy. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81479) provided May 18, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Hyalgan.
You asked the Plan to pre-approve Hyalgan. You say that you are appealing with the most recent medical chart notes. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Orthovisc, Synvisc, and Synvisc-One before it will approve Hyalgan.
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 Hyalgan. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Hyalgan. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Orthovisc, Synvisc, and Synvisc-One. The record does not show that these drugs would likely be less effective and/or 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Hyalgan.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta.
You asked the Plan to pre-approve Neulasta. You say that the medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 Neulasta. Our reviewer says that the medication is not medically necessary. Our physician reviewer found there is no documentation provided indicating 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 Neulasta have not been met. Therefore, we decided that the Plan does not have to pre-approve Neulasta.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for speech generating device equipment provided on December 21, 2020.
You asked the Plan to pay for speech generating equipment. You say that the enrollee needs this device to be able to communicate. The Plan denied your request. The Plan says the denial of payment for these items is correct, because valid proof of delivery for the billed items has not been submitted.
The Plan must follow Medicare rules. Medicare rules say that proof of delivery is required for coverage of durable medical equipment, prosthetics, and orthotics (DMEPOS) items. We looked at the file and Medicare rules. Valid proof of delivery was not submitted for the specific items billed on this claim. Specifically, the delivery tickets submitted do not match the date of service of December
21, 2020. Based on this information, we decided that Medicare rules for coverage of speech generating equipment have not been met. Therefore, we decided that the Plan does not have to pay for speech generating device equipment provided on December 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from 
May 11, 2021, through May 19, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the 
care could have been provided at a lower level. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the enrollee presented to the emergency department (ED) from the skilled nursing 
facility (SNF) with altered mental status and was found to have a urinary tract infection. The enrollee was 
given intravenous fluids and antibiotics and improved rapidly. The enrollee was noted to be anemic and was 
monitored and transfused one unit of blood on May 16, 2021. The enrollee was stable throughout the 
admission. Her condition stabilized and improved, and she was transferred back to the SNF when considered 
medically stable on May 19, 2021. The review has determined that the record did show that at the time of 
inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care 
(including earlier ED and/or observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from May 11, 2021, through 
May 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a wide-width wheelchair provided on April 28, 2021, by an out-of-network provider.
You asked the Plan to pay for a wide-width wheelchair. You say that you need the money at issue to pay your bills and thought that the Plan would pay a percentage of the price of the item. The Plan denied your request. The Plan says rules for payment for out-of-network care have not been met.
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 items/services 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 wide-width wheelchair provided on April 28, 2021, by an out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided from April 20, 2021 to April 22, 2021.
You asked the Plan to waive the copayment for the SNF services. You say that you feel the enrollee should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says the enrollee received SNF care from April 20, 2021 to April 22, 2021. The Plan says that the correct copayment has applied per the enrollee's contract with the Plan.
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 a $0 copayment per day for days 1-20 and a $178 copayment per day for days 21-100 for Skilled nursing facility (SNF) care.
We looked at the file, the Plan's contract and Medicare rules. The file shows that the enrollee received SNF services from April 20, 2021 to April 22, 2021 (days 21-22). The enrollee has been asked to pay a $178 copayment per day for days 21 and 22 for the SNF services, totaling $356. The SNF services fall within the Skilled nursing facility (SNF) care benefit category. This means that 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 for the skilled nursing facility (SNF) services provided from April 20, 2021 to April 22, 2021.
Your complaint about the enrollee only being at the facility for a short period of time 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (81407, 81408 and 81479) provided March 1, 2021.
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular genetic risk assessment panels. We looked at the file and Medicare rules. The services at issue are for screening purposes and are non-covered under Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81407, 81408 and 81479) provided March 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for the 2021 Wellness Allowance for an annual health club membership.
You asked the Plan to reimburse you an additional amount for the 2021 Wellness Allowance for an annual health club membership. The Plan denied your request. The Plan says proof of payment of $99 for a 12-month membership from April 30, 2021, to April 30, 2022 which adds up to 99/12=8.25 per month, 8.25 x 9 months of 2021 = 74.25. The difference of $24.75 has been denied since this falls in year 2022. You have been reimbursed the $74.25 for the 9 months in 2021 and no other proof of payment was received for the additional $24.75 for 2021.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage under the Wellness Allowance benefit. For that reason, the Plan's coverage rules apply in this case. The Plan's rules for coverage of gym benefits have not been met because no other proof of payment was
received for the additional $24.75 for 2021. Therefore, we decided that the Plan does not have to reimburse you an additional amount for the 2021 Wellness Allowance for an annual health club membership.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered by the out-of-network 
(OON) provider on May 26, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of 
network provider, without prior authorization. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 laboratory services rendered by the out-of-network (OON) provider on  
May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home visits and debridement provided on January 12, 2021, to March 17, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the home visits and debridement. You say that the services were 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 services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the home visits and debridement provided on January 12, 2021, to March 17, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services you received on May 14, 2021.
You asked the Plan to waive the copayment for the ambulance services. You say that you don't think you needed an ambulance and you could have taken a different mode of transportation. The Plan denied your request. The Plan says you were charged this copayment 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 $250 copayment per trip for ambulance services. You have been asked to pay a $250 copayment per trip for the ambulance services. This copayment applies regardless of the reason for the transport. 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 services you received on May 14, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the anticoagulant services provided on May 28, 2021.
You asked the Plan to waive the copay for the services provided. You say that you have never had to pay for blood work services with any other insurances. The Plan denied your request. The Plan says the claim processed 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 $40 copay for each specialist visit.
The file shows that you received anticoagulant management services. You have been asked to pay $11.92 for the services provided. Because the amount is less than the $40 copay, you were charged the lesser amount. The services fall within the physician 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 copay for the anticoagulant services provided on May 28, 2021.