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

We decided that the Plan does not have to reduce the coinsurance for the colonoscopy provided on September 10, 2019.
You asked the Plan to reduce the coinsurance for the colonoscopy. You say that you did not know the hospital was no longer in-network. You say if this was in-network you would not have a cost share for a preventive test. 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 20% coinsurance for outpatient surgery or procedure at an out-of-network outpatient hospital or ambulatory surgical center. You have been asked to pay $312.24 which is 20% of the allowed amount for the colonoscopy. The allowed amount is $1,561.22. ($1,561.22 x 20% = $312.24). The colonoscopy 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 reduce the coinsurance for the colonoscopy provided September 10, 2019.
Please note that the Explanation of Benefits (EOB) issued to you for this claim contains inaccurate information regarding the allowed amount of the claim. Please contact the health plan to receive a corrected Explanation of Benefits
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650), an ankle-foot orthosis (L1971), and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 7, 2019.You asked the Plan to pay forthe orthoses. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora lumbar-sacral orthosis (L0650), an ankle-foot orthosis (L1971), and a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on October 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on October 5, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment. 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 $90 copayment for each visit. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit 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 the emergency room visit provided on October 5, 2019.
Your complaint that this was a work injury 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Libre sensors.You asked the Plan to pre-approve FreeStyle Libre sensors. You say that the CGM is helping you control your glucose levels. The Plan denied your request. The Plan says criteria for a CGM have not been met and therefore supplies are not covered.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. The record shows you are not insulin injecting three or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Libre sensors
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on September 11, 2019.You asked the Plan to waive the copayment for the x-ray. You say that in the past when you have had an x-ray in conjunction with your office visit you have only had to pay one copayment. 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 $30 copayment for Medicare-covered x-rays and ultrasounds. You have been asked to pay a $30 copayment for the x-ray. The x-ray 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 the x-ray provided on September 11, 2019.Our decision is only about the 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on October 7, 2019.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 requested provider in this case is not a network provider with the Plan. 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 nurse practitioner services provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99190) provided to the enrollee on September4, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says payment for this service would be included in the Part A DRG payment to the facility.The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99190) provided to the enrollee on September 4, 2019.
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 enrollee's case is more complex because of his cancer diagnosis. You say that IRF care is medically necessary for the enrollee's hip fracture The Plan denied your request. The Plan says IRF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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, based on the medical records provided, the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does require skilled physical therapy and occupational therapy but, based on the medical records provided, does not require treatment in an intensive rehabilitation therapy program. Based on the medical records provided there does not appear to be a need for the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility and treatment at the skilled nursing facility level appears appropriate. 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Phrenic Nerve Stimulation System Procedure at the facility.

You asked the Plan to pre-approve a Phrenic Nerve Stimulation System Procedure (0424T). You say that the enrollee has exhausted all other treatment options and requires therapy with phrenic nerve stimulation. The Plan denied your request. The Plan says the requested service is not covered by Medicare.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Phrenic Nerve Stimulation System Procedure (0424T) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Phrenic Nerve Stimulation System Procedure at the facility.
Appeal type: Other
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveOne Touch Ultra Test Strips for the enrollee.You asked the Planto pre-approvethe strips. You say that this is medically necessary.The Plandenied your request. The Plansaysthereis no medical reason to not be able to use the preferred meters and strips.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 strips. Our reviewer says that the requested strips are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided there is no indication that the plan's preferred test strips would not meet the enrollee's needs.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 strips have not been met.Therefore, we decided that the Plandoes not haveto pre-approveOne Touch Ultra Test Strips for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveViibryd for the enrollee.You asked the Plan to pre-approvethe drug. You saythat this is medically necessary.The Plan denied your request. The Plan says this is a drug that you take orally.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveViibryd for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments fora screening cytopathology (G0123), and a metabolic panel test (80048) provided on October 17, 2019.You asked the Plan to waive the copayments fora screening cytopathology, and a metabolic panel test. You say that you would like to appeal claims associated with your pap smear on October 17, 2019. You were sent two separate bills for $5 each for the service. You are wondering why you received a bill for this when it is supposed to be zero. You would like these claims reviewed because you do not think you should have to pay these copays.The Plan denied your request. The Plan says outpatient diagnostic lab services have a $5 copayment.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 $5 copayment for outpatient diagnostic lab services. You have been asked to pay a $5 copayment for a screening cytopathology, and a metabolic panel test. These servicesfall within the outpatient diagnostic lab services benefit category($5 x 2 = $10). 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 haveto waive the copayments forobtaining a screening cytopathology (G0123), and a metabolic panel test (80048) provided on October 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided on March 15, 2019.
You asked the Plan to pay for these drugs. The Plan denied your request. The Plan says that these drugs are covered under Part D.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided on March 15, 2019.
Benefits for these drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for an outpatient surgery provided on June 4, 2019 by an out of network (OON) provider.You asked the Plan to pay foran outpatient surgery. You say that you were told that prior authorization was not required for these services.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are in-network providers available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of areaurgent care and pre-approved care.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. 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 foran outpatient surgery provided on June 4, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve Zilretta injection.You asked the Plan to pre-approve the injection. You say that this is medically necessary, as you cannot walk or bear weight on your leg.The Plan denied your request. The Plan says that the medication has not been prescribed according to FDA-approved recommendations for use.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.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 has not provided any medical records for MAXIMUS to review. It is not clear if they requested medical records in the first place.Therefore, we decided that the Plan has to pre-approve Zilretta injection.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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy rendered to enrollee from February 6, 2019 to July 8, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The Plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies.We looked at the file and Medicare and the Plan's rules. Based on this information, we decided that Medicare and the Plan's rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay for the home infusion therapy rendered to enrollee from February 6, 2019 to July 8, 2019.Benefits for these services may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided on September 10, 2019.You asked the Plan to waive the copayment for outpatient hospital services. You say that you had this service before and did not have to pay this copayment.The Plan denied your request. The Plan says the correct copayment has been 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 $60-$350 copayment for outpatient hospital services/most outpatient hospital services. You have been asked to pay $264.69 which falls in between the copayment range of $60-$350 for outpatient hospital services. When services are performed in an outpatient hospital setting or the physician is associated with a hospital, an outpatient hospital copayment can be applied. Outpatient hospital services fall within the outpatient hospital services/most 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 outpatient hospital services provided on September 10, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePremarin 0.625mg tablets.You asked the Plan to pre-approvePremarin. You say that the drug is medically necessary.The Plan denied your request. The Plan says this type of self-administered drug is not eligible for coverage under Medicare Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types whichare covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvePremarin 0.625mg tablets.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the brain renderedon October 6, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are a duplicate claim line.
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC. The provider submitted a claim for procedure code 70450-26. The file does not show that the PC was performed in a different payment locality than the TC. The PC of this code is not separately payable. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the brain rendered on October 6, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a diagnosis of age-related osteoporosis without a current fracture. The records do not show that you have tried and failed the plan's required drug of zoledronic acid or that thedrug would be less effective or have adverse affects; therefore, Prolia is not reasonable or 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approveProlia