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

We decided that the Plan does not have to pay for the medical services provided on September 12, 2019 by an out of network (OON) provider.
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 were rendered by a non-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 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 for the medical services provided on September 12, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe head and neck CT scans provided on October 2, 2019.You asked the Plan to waive the coinsurance forthe head and neck CT scans. You say that you should not have to pay for the scans because they were of no use to your medical well-being. 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% of the allowed amount for diagnostic radiology, MRI/CT/CAT/SPECT/PET, Nuclear Cardiology and radiation therapy. You have been asked to pay a total of $460.03 for the head and neck CT scans. The head and neck CT scans fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The medical record shows these scans were performed. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forthe head and neck CT scans provided on October 2, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvetotal electric hospital bed (E0265).You asked the Plan to pre-approvethe total electric hospital bed. You say that the mechanical bed would allow the enrollee to effectively sleep at a 45 degrees and reduce the enrollee's supine hypertension.The Plan denied your request. The Plan says total electric hospital beds are not covered because the height adjustment feature is a convenience feature.The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered. While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item.Therefore, we decided that the Plan does not have to pre-approvetotal electric hospital bed (E0265)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a walk-in shower.You asked the Plan to pre-approve a walk-in shower. You say that you will be in danger of falling without a walk-in shower and you have a prescription.The Plan denied your request. The Plan says a walk-in shower is not primarily medical in nature and therefore not covered by Medicare or the Plan.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Medicare does not cover home modifications.Therefore, we decided that the Plan does not have to pre-approvea walk-in shower
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the office visit (99203) aspiration (20610) and Methylprednisolone injection (J1040). You say that you were told by the provider that your insurance would be accepted. The Plan denied your request. The Plan says services from non-participating providers are not covered under your plan unless they are authorized before the services are provided.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider. Your complaint about obtaining incorrect information 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-approvea Freestyle Libre continuous glucose monitor (CGM) and supplies for the enrollee.You asked the Plan to pre-approvea CGM and supplies. You say that this helps better monitor the enrollee's blood sugar.The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered when the above criteria have been met. We looked at the file and Medicare rules. The file indicates the enrollee is not treated by insulin injections three or more times a day. Based on this information, we decided that Medicare rules for coverage of a CGM and supplies have not been met.Therefore, we decided that the Plan does not have to pre-approvea Freestyle Libre continuous glucose monitor (CGM)and supplies for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approveplacement of an intravascular stent of the cervical carotid artery.You asked the Plan to pre-approvestent placement surgery. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this procedure is not medically necessary.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 stent placement surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation that the enrollee would be a poor candidate for carotid endarterectomy, a procedure that presumably would be covered by the Plan. It is not clear if the provider considering this procedure is aware of the densely calcified plaque at the origin of the right internal carotid artery, a possible anatomic exclusion for this procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of stent placement surgery have not been met.Therefore, we decided that the Plan does not have to pre-approveplacement of an intravascular stent of the cervical carotid artery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe domiciliary visit provided on August 27, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that the services were provided to the enrollee in good faith. You also say that the hospital's staff failed in taking the proper steps to obtain authorization for the services.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says that the enrollee's primary care physician did not refer them for the services. The Plan also says that the services could be provided in network.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 referring provider is not a network provider either. The Plan has network providers available who can provide the items/services at issuein 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 forthe domiciliary visit provided on August 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for podiatry services provided on October 15, 2019.You asked the Plan to waive the copayment forpodiatry services. You say that you received routine podiatry services and disagree with the charges.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 $40 copayment for podiatry services. The medical records show that you received podiatry services on October 15, 2019 due to an ingrown toenail. Therefore, you are responsible to pay the $40 copayment. You have been asked to pay a $40 copayment for podiatry services. Podiatry services fall within the podiatry 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 forpodiatry services provided on October 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve miscellaneous wheelchair accessory, transit package (K0108).You asked the Plan to pre-approve miscellaneous wheelchair accessory, transit package. You say that you are a post-polio patient and your right leg is useless and your left hip is going so you need the motorized wheelchair and its accessories to keep your independence.The Plan denied your request. The Plan says this item is a convenience item and is therefore not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue inthis appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvemiscellaneous wheelchair accessory, transit package (K0108).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on September 24, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the codes were not billed with the required -QW modifier.The Plan must follow Medicare rules. The rules say that all laboratories must have a CLIA certificate in order to receive reimbursement from Federal programs. We looked at the file and Medicare rules. The file shows that the laboratory was not properly CLIA certified and the codes were not billed with the required -QW modifier for CLIA waived testing. 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 pay forthe laboratory services rendered to the enrollee on September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on September 24, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that there are in-network providers available for these services.
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 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 for an office visit provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forTocilizumab injections provided from May 8, 2019 to October 1, 2019.You asked the Plan to waive the coinsurance forTocilizumab injections. You say that you cannot afford the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say aplan 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 Medicare Part B prescription drugs.Date of ServiceService CodeAllowed AmountAmount You Owe5/8/2019Tocilizumab Injection$1,519.22$303.846/5/2019Tocilizumab Injection$2,902.62$579.927/3/2019Tocilizumab Injection$3,010.78$614.927/31/2019Tocilizumab Injection$2,899.62$579.928/28/2019Tocilizumab Injection$2,899.62$579.9210/1/2019Tocilizumab Injection$2,899.62$579.92The total amount you owe is: $3,238.44.You have been asked to pay the total coinsurance amount of $3,238.44 for Tocilizumab injections. Tocilizumab injections fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance forTocilizumab injections provided from May 8, 2019 to October 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe insertion of interlaminar/interspinousprocess stabilization/distraction device (22869 and 22870).You asked the Plan to pre-approvethe insertion of interlaminar/interspinous process stabilization/distraction device. 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 the insertion of interlaminar/interspinous process stabilization/distraction device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested procedure is considered experimental/investigational because there has not been a robust head to head trial with the gold standard of surgical decompression and there is a significant risk of re-operation. Additionally, the studies to date refer to a single level of interspinoius spacer rather than two levels. Therefore, the requested procedure is deemed not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the insertion of interlaminar/interspinous process stabilization/distraction device have not been met.Therefore, we decided that the Plan does not have to pre-approvethe insertion of interlaminar/interspinous process stabilization/distraction device (22869 and 22870).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe CT scan provided on September 16, 2019.You asked the Plan to waive the copayment forthe CT scan. You say that you do not feel you should have to pay this copayment. You say the hospital told you this would be covered with no charge. 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 $250 copayment for advanced imaging services. For this date of service, you havebeen asked to pay the allowed amount of the claim because this amount is less than the $250 copayment for the CT scan.You have been asked to pay a $95.67 copayment for the CT scan. The CT scan 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 forthe CT scan provided on September 16, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe comprehensive oral evaluation provided on October 3, 2019.You asked the Plan to pay forthe comprehensive oral evaluation. You say that your provider did not know that you had already exhausted your comprehensive oral exam benefit. You also say that you should have only had a limited oral exam at the time of this visit.The Plan denied your request. The Plan says your benefit maximum for comprehensive oral exams has been met. The Plan also says that services and/or supplies are limited either by dollar amount, duration, or number of visits, and you have reached this limit.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, comprehensive oral exams are limited to one every 36 months. The record shows that you received a comprehensive oral exam on July 18, 2018 and your comprehensive oral exam benefit is now exhausted.Therefore, we decided that the Plan does not have to pay forthe comprehensive oral evaluation provided on October 3, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the polycarbonate lens (V2784) and photocromatic lens (V2774)
provided October 10, 2019.
You asked the Plan to pay for the lenses. You say that before receiving the service you called the provider
office and was told that you qualified for the eyeglasses The Plan denied your request. The Plan says that these
services are not covered under the vision benefit package.
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. The Plan covers these services when up to $100 for eyeglasses (frames and lenses) or up to $100 for
contact lenses every 2 years.
We looked at the file and the Plan's rules. The plan says that per the Evidence of Coverage only single vision,
lined bifocal or trifocal lenses are covered. The Evidence of Coverage does not indicate any limitations on the
type of lenses that is covered or not covered by the plan. Based on this information, we decided that the Plan's
rules for coverage of the lenses have been met. Therefore, we decided that the Plan has to pay for the
polycarbonate lens (V2784) and photocromatic lens (V2774) provided October 10, 2019.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CTA scan of the heart (75574).
You asked the Plan to pre-approve the CTA scan of the heart. You say that the CTA is medically necessary
because the member has chest pains and abnormal dobutamine. The Plan denied your request. The Plan says
the records show that approval for the same test or one like it is on file and a new test cannot be approved
without knowing the outcome of the prior approval.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 CTA scan of the heart. Our
reviewer says that the documentation does not include a discussion or rationale for the requested CT scan. Our
physician reviewer found without the support of the documentation, medical necessity cannot be determined.
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 CTA scan of the heart have not been met. Therefore, we decided that the
Plan does not have to pre-approve a CTA scan of the heart (75574).