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

We decided that the Plan does not have to waive the copayment for the ultrasound provided on July 11, 2019.
You asked the Plan to waive the copayment for the ultrasound. You say that you have been charged the correct cost sharing amount. 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 $100 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $100 copayment for the ultrasound.
You have been asked to pay a $60.37 copayment for the ultrasound. The ultrasound falls within "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows the ultrasound was not billed as a part of the screening mammogram.
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 ultrasound provided on July 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Invokana.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under 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 which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Invokana.
Benefits for this drug 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 pay for the medical services provided on August 29, 2019 by out of network provider.
You asked the Plan to pay for physician services. You say that you would like the Plan to review your medical records and issue payment. The Plan denied your request. The Plan says there are in-network providers available for the services that were 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 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 August 29, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided on July 22, 2019.
You asked the Plan to waive the copayment for a specialist office visit. You say that you are being charged for both visits. You say that you only had to come back because they were unable to give you the services you needed on the first visit. 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 $45 copayment for physician/practitioner services/in-network/specialists visit. You have been asked to pay a $45 copayment for a specialist office visit. Since a specialist office visit was provided, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/in-network/specialists visit 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 specialist office visit provided on July 22, 2019.
We note your complaint about having to go back for a second visit. 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 pre-approve Oncotype DX Prostate Cancer Assay.
You asked the Plan to pre-approve Oncotype DX Prostate Cancer Assay. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
The Plan follows Medicare rules. Medicare rules say that prostate cancer assays are only covered for certain indications. 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 Oncotype DX Prostate Cancer Assay. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee was recently diagnosed with prostate cancer. While the enrollee had cancer in only 1 of 12 biopsy cores, the Gleason score was 3+4 = 7. The current treatment plan is not documented. There is no documentation as to how the requested testing will alter the enrollee's diagnosis or treatment. Therefore, the enrollee does not meet criteria for the requested services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Oncotype DX Prostate Cancer Assay have not been met. Therefore, we decided that the Plan does not have to pre-approve Oncotype DX Prostate Cancer Assay.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neulasta for chemotherapy-induced neutropenia.
You asked the Plan to pre-approve the Neulasta. You say that the enrollee needs to the Neulasta to combat neutropenia caused by chemotherapy. This is not caused by the study drugs and is medically necessary. The Plan denied your request. The Plan says the Taxotere/carboplatin chemotherapy is being provided by the clinical trial as a routine cost. Use of Neulasta for side effects from this would also be a routine cost. This is to be billed to Original Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve the Neulasta as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Neulasta for chemotherapy-induced neutropenia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 24, 2019 by out of network provider.
You asked the Plan to pay for chiropractic services. You say that you are in-network. The Plan denied your request. The Plan says the enrollee's primary care physician did not refer these services. The plan says that there are in-network providers 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 the medical services provided on July 24, 2019 by out of network provider.
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 none of the skilled nursing facilities do peritoneal dialysis.The Plan denied your request. The Plan says the enrollee does not meet the requirements for approval. The plan says that the enrollee can safely receive the necessary services in another setting. The plan says that the provider is a NSF that has a bed available for peritoneal dialysis.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 the enrollee's prior level of function was living in a trailer with a friend and requiring assistance with mobility and bathing and toileting. Our physician reviewer found that the enrollee's current level of function is standby assist with grooming, refusing transfers, refusing further activities of daily living, and maximal assist with bed mobility. Our physician reviewer found that the enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient physical medicine and rehabilitation physician three times per week or acute rehab nursing care. Our physician reviewer found that, while the enrollee may benefit from continuing physical therapy and occupational therapy, there is no evidence of a need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care.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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services requested on January 2, 2020.
You asked the Plan to pre-approve the SNF services. You say that the enrollee needs this care. The Plan denied your request. The Plan says the enrollee's SNF benefit remain exhausted for this benefit period which has not ended. The enrollee has not gone more than 60 days without inpatient hospital or SNF care.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from February 2, 2019 to January 2, 2020. The 100th day was used on July 9, 2019. The Plan has covered 100 days of SNF care. A new benefit period has not started since the 100th day was used. Although the enrollee may need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when she has not been receiving care in a hospital or skilled care in a SNF for at least 60 days in row. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services requested on January 2, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider on September 2, 2019, and September 9, 2019.
You asked the Plan to pay for the services. You say that the plan lab provides inaccurate results. The Plan denied your request. The Plan says the services were 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 has network providers available who can provide 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 services provided to you by an out-of-network provider on September 2, 2019, and September 9, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the outpatient mental health visits
provided from April 11, 2019 to August 5, 2019.
You asked the Plan to reduce the copayment for the outpatient mental health visits. You say that you should
only be charged a $20 copayment because the provider is a specialist. 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 $40
copayment per visit for outpatient mental health care.
You have been asked to pay a $40 copayment for each of the outpatient mental health visits. The outpatient
mental health visits fall within the "Outpatient mental health care" benefit category. The record shows the
provider is a psychiatrist.
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 copayment for the outpatient mental health visits provided from April 11,
2019 to August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the first hour of critical care (99291) provided on July 28, 2019.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the record does not indicate that 30-74 minutes of critical care services were rendered on this date of service. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the first hour of critical care (99291) provided on July 28, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for massage therapy provided from April 11, 2019 to May 16, 2019.
You asked the Plan to pay for massage therapy. You say that these services help relieve your neck and back pain. The Plan denied your request. The Plan says this is not a covered benefit under Medicare or the Plan.
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, we decided that the Plan does not have to pay for massage therapy provided by The Sore Spot from April 11, 2019 to May 16, 2019.
Sincerely,
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for blood glucose test or reagent strips (A4253), lancets (A4259), calibrator solution / chips (A4256), and replacement battery, lithium (A4235) provided from August 19, 2019 to November 7.
You asked the Plan to pay for blood glucose test or reagent strips, lancets, calibrator solution / chips, and replacement battery, lithium. You say that the items were provided and payment should be rendered. The Plan denied your request. The Plan says the documentation provided did not include a valid proof of delivery. Therefore, coverage criteria has not been met.
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. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Specifically, the delivery ticket is missing a valid signature. Therefore, we decided that the Plan does not have to pay for blood glucose test or reagent strips (A4253), lancets (A4259), calibrator solution / chips (A4256), and replacement battery, lithium (A4235) provided from August 19, 2019 to November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the office visit and eye exam provided on June 7, 2019 and August 9, 2019.You asked the Plan to waive the copayments for the office visit and eye exam. You say that you were informed the provider was in-network. You say that you are expecting to pay a $45 copayment.The Plan denied your request. The Plan says the copayments applied correctly.The rules say a plan must disclose to itsenrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $75 copayment for each Medicare-covered out-of-network examand eye exam to evaluate for eye disease. Covered services include outpatient physician services provided by an ophthalmologist or optometrist for the diagnosis and treatment of diseases and injuries of the eye.You have been asked to pay a $75 copayment for the office visit and a $75 copayment for the eye exam. The total amount you owe is $150 ($75 + $75 = $150). The office visit and eye exam fall within the "Vision care" benefit category. The records show that the provider is out-of-network. 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 the office visit and eye exam provided on June 7, 2019 and August 9, 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 you disagree with the denial. The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on November 28, 2019. The physical therapy progress note from November 30, 2019 states she needed supervision to sit up and lie down and minimal assistance to walk 50 feet with a walker. She has no complex issues that require the intensity of services in an IRF. She may benefit from further therapy but does not require an intensive therapy program in an IRF. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services provided on August 8, 2019.
You asked the Plan to pay for the ophthalmological services. You say that the enrollee resides in a nursing
facility and relies on the facility staff for all of his needs. You say that the enrollee did not have any input on
who would be the optometrist that would perform his vision exam. You say that the physician does not know
which patients she will be seeing prior to the exam. The Plan denied your request. The Plan says there is no
valid referral for this service.
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
service 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 ophthalmological services provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 8, 2019.
You asked the Plan to pay for the physician's 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 physician's services provided on August 8, 2019.