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

We decided that the Plan has to pay forlaboratory testing provided on July 26, 2019.You asked the Plan to pay forlab tests. You say that you are a reference laboratory and the only medical records that you can supply are the ordering requisition and results.The Plan denied your request. ThePlan says that the denial of payment for these services is correct, because the Plan could not obtain the ordering provider's progress notes to determine the clinical utility of the testing.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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given bya contract provider are considered approved by the plan unless notice is provided that the services will not be covered.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 did not specify whether the ordering physician is in-network or out-of-network with the Plan. Without this information, we cannot determine whether the lab order made constitutes plan-directed care, which would justify coverage of these tests. The documentation submitted does not show that the Plan provided prior notice that these tests would not be covered. Therefore, the Plan has not shown that their decision to deny payment for these tests is correct or justified according to Medicare rules. Therefore, we decided that the Plan has to pay forlaboratory testing provided on July 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care provided on December 11, 2018 by an out of network (OON) provider.You asked the Plan to pay forthe wound care. You say that emergency wound care was provided to the enrollee in the absence of an available wound care physician.The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan says the services were routine in nature. The Plan also says the services could have been performed in plan.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 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 forthe subsequent nursing facility care provided on December 11, 2018 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that the enrollee was choking and so you called 911. When paramedics arrived, the enrollee had stopped choking and they evaluated his vitals. You say that they asked you if transportation to the hospital was needed, and you declined because he was fine. The Plan denied your request. The Plan says these services are not a covered benefit.
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 November 26, 2018. 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 services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveGenotropin MiniQuick pens.You asked the Planto pre-approveGenotropin MiniQuick pens. You say that this is medically necessary for the enrollee's condition.The Plandenied your request. The Plansaysthis self=injected drug is not covered by 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 which are covered by Medicare Part B.Therefore, we decided that the Plandoes not haveto pre-approveGenotropin MiniQuick pens.Benefits for Genotropin MiniQuick pensmay be available under Medicare Part D.Contactthe 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 pre-approve genicular nerve ablation of the knee for the enrollee.You asked the Planto pre-approvethe injection. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is a lack of literature with true head-to-head comparisons to other standard treatments.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 injection. Our reviewer says that the requested injection is not considered medically reasonable and necessary in this case. Our physician reviewer found this is still considered an experimental/investigational procedure that is the subject of on-going clinical trials. The current literature lacks head to head trials and robust trials. Therefore, the request is considered 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 injection have not been met.Therefore, we decided that the Plandoes not haveto pre-approvegenicular nerve ablation of the knee for the enrollee
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Polysomnography (95810).You asked the Plan to pre-approve Polysomnography. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 95810 duplicates diagnostic portion of approved split night study.The Plan follows Medicare rules. Medicare rules say that the results of the sleep tests identified below can be used by a beneficiary's treating physician to diagnose OSA, that the use of such sleep testing technologies demonstrates improved health outcomes in Medicare beneficiaries who have OSA and receive the appropriate treatment, and that these tests are thus reasonable and 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 Polysomnography. Our reviewer says that coverage criteria for 95810, diagnostic PSG, are not met. The Plan has approved 95811, attended PSG split-night study with PAP titration. Our physician reviewer found this is the appropriate test for the member, and the one intended by the clinician, according to the record. 95810 duplicates the diagnostic portion of 95811, and is therefore not medically 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 Polysomnography have not been met. Therefore, we decided that the Plan does not have to pre-approve Polysomnography (95810).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe Part B injections provided from August 2, 2019 to September 26, 2019.You asked the Plan to waive the coinsurance forthe Part B injections. You say that these services should be covered. You say the copayments are a lot of money and cannot afford it.The Plan denied your request. The Plan says you have been charged thecorrect 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 Medicare Part B chemotherapy and non-chemotherapy prescription drugs. You have been asked to pay $1,745.49for the Part B injections. The Part B injections fall within the "Medicare Part B prescription drugs" benefit category. See chart below.  Date of ServiceServiceAllowed AmountCoinsuranceMember LiabilityAugust 2, 2019Part B injection$935.0920%$187.02August 2, 2019Part B injection$623.3920%$124.68August 9, 2019Part B injection$935.0920%$187.02August 23, 2019Part Binjection$935.0920%$187.02August 23, 2019Part B injection$623.3920%$124.68September 6, 2019Part B injection$979.6220%$195.92September 6, 2019Part B injection$578.8620%$115.77September 13, 2019Part B injection$979.6220%$195.92September 13, 2019Part B injection$578.8620%$115.77September 26, 2019Part B injection$979.6220%$195.92September 26, 2019Part B injection$578.8620%$115.77Total$1,745.49This 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 Part B injections provided from August2, 2019 to September 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forcomputed tomography (74177) provided on August 20, 2018.You asked the Plan to pay forcomputed tomography. You say that you filed this claim timely.The Plan denied your request. The Plan says this claim was filed more than a year after the date of service.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for computed tomography was not filed until October 16, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forcomputed tomography (74177) provided on August 20, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an eye exam to treat conditions of the eye provided on October 9, 2019.You asked the Plan to waive the copayment for an eye exam. You say that you expected this eye exam to be fully covered. You say that it has been over 2 years since your last exam.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 vision care/Medicare-covered eye exams. You have been asked to pay a $45 copayment for an eye exam. Since re-evaluation was provided during an office visit the correct copayment has been applied. An eye exam falls within the vision care/Medicare-covered eye exams 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 an eye exam to treat conditions of the eye provided on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for999 units of CPT code J0897 provided on March 19, 2019.You asked the Plan to pay for999 units of CPT code J0897. You say that you would like the plan to reconsider their denial of payment.The Plan denied your request. The Plansays CPT code J0897 is not payable as billed.The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units provided for each procedure code.We find that 999 units of CPT code J0897 are not supported inthe medical record. Based on this information, we decided that Medicare rules for coverage of 999 units of CPT code J0897 have not been met.Therefore, we decided that the Plan does not have to pay for999 units of CPT code J0897 provided on March 19,2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance transport (A0427, A0425) provided by the on April 9, 2019.You asked the Plan to waive the copayment forthe ambulance services. You say that you don't remember receiving the service.The Plan denied your request. The Plan says the correct copayment was 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 $50 copayment for Ambulance Services. You have been asked to pay a $50 copayment for the ambulance services. The ambulance transport falls within the Ambulance 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 foran ambulance transport (A0427, A0425) provided on April 9, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit and X-Ray examination
provided on September 26, 2019.
You asked the Plan to waive the deductible for office visit and X-Ray. You say that this was the last follow-up
appointment after your surgery and should have been paid the same as the previous appointments. The Plan
denied your request. The Plan says the deductible 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. Your
contract with the Plan says that there is $750 deductible for out-of-network office visit and X-Ray exam. At the
time this claim was processed, $0 of the $750 deductible had been met. The allowed amount of the claim is
$113.75, resulting in a deductible obligation of $113.75.
The items or services you asked the Plan to waive the deductible for fall within the benefit categories
"Physician/Practitioner Services, Including Doctor's Office Visits" and "Outpatient Diagnostic Tests and
Therapeutic Services and Supplies". The Plan has followed Medicare rules by clearly disclosing in the contract
that there is $750 deductible for out-of-network office visit and X-Ray. This cost sharing is a contractual
obligation that had not been met at the time office visit and X-Ray was received on September 26, 2019.
Therefore, we decided that the Plan does not have to waive the deductible for an office visit and X-Ray
examination provided on September 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer.
You asked the Plan to pre-approve the Superion spacer. You say that the enrollee would benefit from this procedure. The Plan denied your request. The Plan says this is not covered for enrollees with a BMI of over 40.
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 Superion spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found This enrollee presents with chronic low back and bilateral lower extremity pain, with signs/symptoms consistent with neurogenic claudication. Functional limitations are documented in activities of daily living and affect her quality of life. Clinical exam findings are generally consistent with imaging evidence of mild central and neuroforaminal stenosis at the L3/4 and L4/5 levels. She has reportedly failed to achieve adequate improvement with conservative treatment. Under consideration is a request for the Vertiflex Superion spinal spacer device at the L3/4 and L4/5 levels. FDA criteria have not been met to support the medical necessity of this procedure. There is no clear imaging evidence of moderate degenerative spinal stenosis for which this procedure is indicated. Additionally, the enrollee's body mass index is 44.12. FDA contraindications for this procedure include body mass index greater than 40. Therefore, this request for the Superion spinal spacer device is 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 Superion spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve placement of a Superion interspinous spacer.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory testing provided on September 4, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the laboratory testing. You say that the ordering provider requested the services because they were not available from contracted providers. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says 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 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 laboratory testing provided on September 4, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the member clearly exceeds the CMS established defining criteria for an appropriate LTACH admission. The Plan denied your request. The Plan says medically necessary acute and critical care at the current facility will continue to be covered until the member's condition is stable for transfer to a lower level of care.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there are no services available at the LTACH that aren't already being offered and covered at the current acute care facility. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 18, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency 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 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 medical services provided to the enrollee by an out-of-network provider on September 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CPAP supplies provided on October 2, 2019 by an OON provider.You asked the Plan to pay forthe CPAP supplies. You say that the supplies were medically necessary.The Plan denied your request. The Plan says you did not request 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 at issue in this appeal. The Plan did not pre-approve the itemsat issue. We found no exception that would require the Plan to pay for these items.Therefore, we decided that the Plan does not have to pay forthe CPAP supplies provided on October 2, 2019 by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for medical nutrition therapy provided on August 1, 2019.
You asked the Plan to pay for medical nutrition therapy services. You say that you are requesting payment for this service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because medical nutrition therapy is not covered by Medicare for the diagnoses billed on this claim.
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services only for enrollees with renal disease or diabetes. Records do not show that the enrollee suffers from renal disease or diabetes. Therefore, we decided that the Plan does not have to pay for medical nutrition therapy provided on August 1, 2019.