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

We decided that the Plan does not have to pay for the Shingles vaccine provided on April 12, 2021.

You asked the Plan to pay for the Shingles vaccine. You say that you did not know this was a Part D service that could not be done at a clinic. The Plan denied your request. The Plan says the Shingles vaccine is a Medicare Part D covered service and does not have coverage under your Medicare Part B insurance.

In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the Shingles vaccine. The Plan follows the same rules. 

Records do not show that you have been injured or directly exposed to any illness related to the Shingles vaccine. Therefore, we decided that the Plan does not have to pay for the Shingles vaccine provided on April 12, 2021.

Benefits for the Shingles vaccine 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on November 12, 2020.

You asked the Plan to pay for ambulance response and treatment, no transport. The Plan denied your request. The Plan says Medicare does not cover when paramedics only come out to your house but do not transport you.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. The file shows that that ambulance medical records were not provided to determine whether payment is due. Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on November 12, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic colonoscopy procedure provided on December 9, 2020 by an out-of-network provider.
You asked the Plan to pay for the diagnostic colonoscopy procedure. You say that the services were required to maintain health according to accepted medical practice, current research and efficiency considerations. The Plan denied your request. The Plan says prior authorization was not obtained as required.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the diagnostic colonoscopy procedure provided on December 9, 2020 by an out-of-network provider.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for lab work. We decided that the Plan does not have to waive the copayment for lab work.
You asked the Plan to waive the copayment for lab work. You say that you would like these copayments paid. The Plan says that the correct copayment has been applied.
We decided that the Plan has to waive the copayment for date of service February 23, 2021.
An Evidence of Benefits was not provided for February 23, 2021. Due to these reasons, a decision for the date in service in question cannot be rendered. Therefore, we decided that the Plan has to waive the copayment for date of service February 23, 2021.
We also decided that the Plan does not have to waive the copayment for lab work.
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 $20 copayment for lab work. There is a $20 copayment per visit for lab work; therefore, you cannot be asked to pay more than $20 for this lab work. Therefore, we decided that the Plan does not have to waive the copayment for lab work.
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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 17, 2021.

You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you cannot pay for this and do not know what to do. The Plan denied your request. The Plan says this service is not covered.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. 

The ambulance company did not provide transport services on February 17, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 17, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for therapeutic continuous glucose monitor (CGM) (K0554) and supply
allowance used with a therapeutic CGM device (K0553) provided November 18, 2020.
You asked the Plan to pay for the CGM device and supply allowance. You say that the medical records
provided support the necessity of the services in dispute. The Plan denied your request. The Plan says that the
documentation did not sufficiently document the enrollee's medical condition to support medical necessity, nor
did the documentation indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered reasonable and
necessary for enrollees with diabetes who meet criteria referenced 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 pay for the CGM device and supply allowance. Our
reviewer says that the requested items/services is considered medically reasonable and necessary in this case.
Our physician reviewer found the enrollee has type 2 diabetes and uses insulin (Lantus and Humalog) which he
injects with meals and at bedtime (4 times daily). Based on the provided documentation, this enrollee appears
to meet criteria for a CGM device.
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 CGM device and supply allowance have been met. Therefore, we decided
that the Plan has to pay for therapeutic continuous glucose monitor (CGM) (K0554) and supply allowance used
with a therapeutic CGM device (K0553) provided November 18, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on February 12, 2021, by an OON provider.

You asked the Plan to pay for chiropractic services. You say that this is a new Plan for the enrollee, and you did not know she needed prior authorization. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 chiropractic services provided on February 12, 2021, by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta.

You asked the Plan to pre-approve Zilretta. You say that this drug is medically necessary for the enrollee's condtion. The Plan denied your request. The Plan says step therapy criteria have 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 Zilretta. Our reviewer says that the requested drug is not medically necessary and reasonable. Our physician reviewer found the enrollee is a 75-year-old female with a history of osteoarthritis of the knee. The Plan requires a trial of Dexamethasone and Triamcinolone before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. 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 Zilretta have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve the SNF admission. You say that the service is medically necessary. The Plan denied your request. The Plan says the service is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have documented skilled nursing or skilled therapy 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 SNF admission have not been met. Specifically, medically necessary services can be provided at a lower level of care. This means admission into a SNF is not medically necessary or reasonable. Therefore, we decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) admission.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on February 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that you were not notified that telehealth services were no longer covered for out-of-network providers. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 psychotherapy services provided on February 4, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the interim upper and lower denture (D5810 and D5811).
You asked the Plan to pre-approve the interim upper and lower denture (D5810 and D5811). You say that you won't be able to eat comfortably until the gums are healed. You say that you need interim dentures to hold over until the permanent dentures are done. The Plan denied your request. The Plan says the services are not covered benefits.
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 pre-approve the interim upper and lower denture (D5810 and D5811).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for skilled nursing facility services provided from March 1, 2021, to April 3, 2021
You asked the Plan to waive the copayments for the skilled nursing facility services. You say that you were not notified that the Plan would only pay for 20 days of your stay. The Plan denied your request. The Plan says your stay is covered, and you were charged the 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 $160 copayment per day for days 21 to 100 for Skilled Nursing Facility Care. You have been asked to pay a $160 copayment per day for days 21 to 100 for the skilled nursing facility services. The skilled nursing facility services fall within the Skilled Nursing Facility 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 copayments for skilled nursing facility services provided from March 1, 2021, to April 3, 2021
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).

You asked the Plan to pre-approve Prolia (J0897) Injection, denosumab, 1 mg. You say that you want the enrollee to be treated with this drug. The Plan denied your request. The Plan says the enrollee has not tried and failed zoledronic acid and there is no indication the enrollee has had an osteoporosis-related fracture.

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 Prolia (J0897) Injection, denosumab, 1 mg. Our reviewer says that the drug is not medically reasonable and necessary. Our physician reviewer found the patient has not tried and failed the required drug. There is no documentation provided indicating that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee. In addition, the enrollee does not have a history of osteoporosis-related fracture. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia (J0897) Injection, denosumab, 1 mg have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergency transport (A0428-HN), and the ground mileage (A0425-HN) provided on January 2, 2021.
You asked the Plan to pay for the ambulance services. You say that you do not have a way of knowing that if a transport requires prior authorization. The Plan denied your request. The Plan says that prior authorization was not obtained for services provided by an out of network provider.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the non-emergent ambulance services have not been met. Specifically, the documentation submitted did not include any clinical information or a trip report to verify if the member's clinical condition was such that other methods of transport would have been contraindicated. Therefore, we decided that the Plan does not have to pay for the non-emergency transport (A0428-HN), and the ground mileage (A0425-HN) provided on January 2, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a defibrillator (K0606) provided on January 23, 2021, by an OON provider.
You asked the Plan to pay for a defibrillator. You say that this should be covered as in-network. The Plan denied your request. The Plan says this was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the 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 defibrillator (K0606) provided on January 23,
2021, by an OON provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid for the Coronavirus (U0003 and U0005) provided on January 5, 2021.
You asked the Plan to pay for the infectious agent detection. You say that you would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the infectious agent detection by nucleic acid for the Coronavirus (U0003 and U0005) provided on January 5, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy with biopsy provided on April 9, 2021.

You asked the Plan to waive the copayment for colonoscopy with biopsy. You say that you went in for a preventive colorectal cancer screening and do not feel that you should be responsible for a copayment. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $200 copayment for colonoscopy with biopsy at an ambulatory surgical center. This colonoscopy included a biopsy, so it is considered to be a surgical service and not a screening or preventive service.

You have been asked to pay $200 copayment for colonoscopy with biopsy. Colonoscopy with biopsy falls within the Outpatient Surgery, Including 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 a colonoscopy with biopsy provided on April 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient lumbar spine surgery.
You asked the Plan to pre-approve T-11 Pelvis instrumentation and L3-4 Posterior segment deformity correction, with one inpatient bed day. You say that it is not safe for your health to not have the surgery. The Plan denied your request. The Plan says the clinical value and effectiveness of the procedure has not been demonstrated in the peer reviewed literature.
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 T-11 Pelvis instrumentation and L3-4 Posterior segment deformity correction, with one inpatient bed day. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found
the patient does not meet criteria for this extensive spinal fusion and reconstructive procedure.
There is no documented physical therapy in the past 12 months for back pain. More conservative measures are needed. There are no red flags for surgery 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 T-11 Pelvis instrumentation and L3-4 Posterior segment deformity correction, with one inpatient bed day have not been met. Therefore, we decided that the Plan does not have to pre-approve an inpatient lumbar spine surgery.