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

We decided that the Plan does not have to pay for nurse practitioner services provided on September 21, 2020.
You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services provided on September 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electroencephalogram (EEG); including recording awake and asleep.

You asked the Plan to pre-approve an EEG. You say that the ER physician recommended you have an EEG. The Plan denied your request. The Plan says an EEG 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 looked at the file and Medicare rules. The record shows the neurologist requested an EEG before you had been seen. There are no medical records to support medical necessity. Based on this information, we decided that Medicare rules for coverage of an EEG have not been met. Therefore, we decided that the Plan does not have to pre-approve an electroencephalogram (EEG); including recording awake and asleep.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a backup battery for an air mattress.
You asked the Plan to pre-approve the backup. You say that this is needed for when the enrollee is out of electric service. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. A backup battery is considered duplicative, and cannot be covered. Therefore, we decided that the Plan does not have to pre-approve a backup battery for an air mattress.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveintravenous immune globulin (IVIG). You asked the Plan to pre-approveIVIG. You say that this is necessary to treat the enrollee's progressive axonal polyneuropathy.The Plan denied your request. The Plan says this is not covered for the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that physicians should avoid prescribing IVIG except for patients with severe immune deficiency and who have low antibody levels or for those whom have other well-established indications for therapy with IVIG as described within the NCD and LCD. We looked at the file and Medicare rules. The enrollee does not have a covered condition described within the NCD and LCD. Based on this information, we decided that Medicare rules for coverage of IVIG have not been met.Therefore, we decided that the Plan does not have to pre-approveintravenous immune globulin (IVIG).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit with your primary care provider (99214) provided on October 14, 2020.
You asked the Plan to waive the copayment for the office visit. You say that you get one annual wellness visit per year at no additional cost to you. The Plan denied your request. The Plan says the office visit included services not covered by an annual wellness visit, and that there is a $5 copayment for an office visit with your primary care physician.
The rules say a Plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for physician and practitioner services. You have been asked to pay a $5 copayment for the office visit. Records of the visit were provided that show you had a flu vaccine, lab testing, and other services provided during this visit that expanded beyond the normal scope of an annual wellness visit. These services fall within the physician and practitioner services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit with your primary care provider (99214) provided on October 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Genvisc injection.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says information about previous treatment, symptoms, or x-ray/MRI results were not provided.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise 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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is no specific documentation that there has been a trial and failure of conservative therapy. The review has determined that the enrollee does not meet the criteria for injection. 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 Plan does not have to pre-approve a Genvisc injection.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services (S9328) provided June 2, 2020 to September 23, 2020.
You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not eligible for Medicare payment.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S9328 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, CPT code S9328 has a status code of "I" which means it is not eligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services (S9328) provided June 2, 2020 to September 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing (0037U) provided August 4, 2020.
You asked the Plan to pay for the genetic testing. You say that the genetic sequencing was medically necessary. The Plan denied your request. The Plan says rules for coverage were not met.
The Plan follows Medicare rules. Medicare rules say that this service is covered when the beneficiary has either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 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 genetic testing. Our reviewer says that the service was not medically necessary. Our physician reviewer found the record does not show that the enrollee had relapsed, recurrent, refractory or metastatic disease. The enrollee's cancer was not stage III or IV. 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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay for genetic testing (0037U) provided August 4, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible forthe colonoscopy provided on August 27, 2020.You asked the Plan to waive the deductible forthe colonoscopy. You say that you cannot afford this 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. Your contract with the Plan says that there is a $750 deductible each outpatient surgery and/or services at an outpatient hospital.The colonoscopy you asked the Plan to waive the deductible for falls within the "Outpatient hospital services" benefit category after the deductible is met for each outpatient surgery and/or services at an ambulatory surgical center or outpatient hospital facility. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible that applies towards each outpatient surgery and/or services at an outpatient hospital facility. This cost sharing is a contractual obligation that had not been met at the time the colonoscopy was received on August 27, 2020. Therefore, we decided that the Plan does not have to waive the deductible forthe colonoscopy provided on August 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with captain's chair.

You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says given the provided documentation, the requirements for this wheelchair have not been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

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 wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found you have a personal mobility deficit, but this deficit is currently helped by a manual wheelchair that allows you to participate effectively with MRADLs in the home. While you may have the cognition to safely use the PMD the documentation does not reveal that you require a PMD to perform MRADLs in the home. 

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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 standard power wheelchair with captain's chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies purchased from July 2, 2020, to October 21, 2020.

You asked the Plan to pay for the diabetic supplies. You say that these supplies were medically necessary. The Plan denied your request. The Plan says you did not have a physician order for the supplies and you obtained durable medical equipment from a provider who does not participate with Medicare.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a physician order. The rules also say no Medicare payment may be made to a beneficiary for items provided directly by a provider who is not eligible to take Medicare payment. 

The record does not contain a valid physician order for the supplies provided in this case. Medicare will only cover blood sugar self-testing equipment and supplies if you have a prescription. Payment cannot be made for items purchased from the online provider because this provider is not a medical provider and is not enrolled in Medicare. Therefore, we decided that the Plan does not have to pay for the diabetic supplies purchased from July 2, 2020, to October 21, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 24, 2020 and August 31, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 physician's services. 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 24, 2020 and August 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 6, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that in most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care.

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 physician's services. 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 July 6, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an addition to a lower extremity prosthesis (L5685) provided on September 3, 2020.

You asked the Plan to waive the coinsurance for the prosthetic addition. You say that you disagree with the cost-sharing. The Plan denied your request. The Plan says prosthetic devices and related supplies are subject to 20% coinsurance.

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 prosthetic devices and related supplies. 

You have been asked to pay $50.20 coinsurance for a prosthetic addition. A prosthetic addition falls within the prosthetic devices and related supplies benefit category. The Plan's allowed amount for this device is $250.98 ($250.98 x 20% = $50.20). 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 for the addition to a lower extremity prosthesis (L5685) provided on September 3, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 2, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that in most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our Plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care.

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 physician's services. 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 September 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a safety belt/pelvis strap for a wheelchair.

You asked the Plan to pre-approve the accessory. You say that you are unable to get to the bathroom in time, or get to the kitchen safely. The Plan denied your request. The Plan says a separate request for a position belt should be denied as unbundled.

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 accessory. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the safety belt/pelvic strap (E0978) is not medically necessary. The documentation notes that you have 3/5 upper body strength, but the documentation does not reveal that you need a safety belt/pelvic strap for positioning. The documentation also does not reveal upper body instability or muscle spasticity that requires the use of the safety belt/pelvic strap for proper positioning. The documentation does not support that the criteria have been met. 

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 accessory have not been met. Therefore, we decided that the Plan does not have to pre-approve a safety belt/pelvis strap for a wheelchair.
Sincerely,
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pre-approve the fertility testing services provided on July 24, 2020, through August 17, 2020.

You asked the Plan to pre-approve the fertility testing services. You say that you would like reconsideration because this testing is medically necessary for your chronic conditions. The Plan denied your request. The Plan says that this testing is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 fertility testing services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found Medicare does pay for infertility services. The HSG radiology test and the laboratory tests should therefore be covered. 

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 fertility testing services have been met. Therefore, we decided that the Plan has to pre-approve the fertility testing services provided on July 24, 2020, through August 17, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Decision-DX Melanoma testing (81599) provided on July 31, 2020.
You asked the Plan to pay for the Decision-DX Melanoma testing. You say that you would like reconsideration because this is a medically necessary, Medicare covered test. The Plan denied your request. The Plan says the member's cancer does not meet the indications for coverage.
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 pay for the Decision-DX Melanoma testing. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the results of analysis of enrollee's melanoma performed with DecisionDx-Melanoma, the tumor was classified as Class 1A with a low risk of near-term (within 5 years) metastatic disease, such as 96% metastasis free rate. There is no peer-reviewed published studies confirming DecisionDx-Melanoma signature may be an independent predictor of metastasis risk. 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 Decision-DX Melanoma testing have not been met. Therefore, we decided that the Plan does not have to pay for Decision-DX Melanoma testing (81599) provided on July 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B chemotherapy drug provided on September 4, 2020.
You asked the Plan to waive the coinsurance for the Part B chemotherapy drug. You say that you are on a fixed income and cannot afford this 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 20% coinsurance for Medicare Part B chemotherapy prescription drugs. You have been asked to pay $1,559.64 which is 20% of the allowed amount for the Part B chemotherapy drug. The allowed amount is $7,798.21. ($7,798.21 x 20% = $1,559.64). The Part B chemotherapy drug falls 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 for the Part B chemotherapy drug provided on September 4, 2020.