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

We decided that the Plan does not have to pay for the shingles vaccine and the administration of the influenza vaccine provided on December 9, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the services are not covered under your plan benefits.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services provided. The Plan follows the same rules. You received the shingles vaccine. The records do not show that you have been injured or directly exposed to any illness related to the shingles vaccine provided. Therefore, we decided that the Plan does not have to pay for the shingles vaccine.
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 G0008 is the administration of the influenza virus vaccine. We find that this code is statutorily excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the administration of the influenza vaccine provided on December 9, 2019.
Benefits for the shingles vaccine may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FARXIGA tab 5mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the requested medication is denied as a benefit exclusion.
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 FARXIGA tab 5mg for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the laser eye services provided on December 11, 2019.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the code was
not billed in accordance to Medicare rules.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service
exceeds the MUE value for the HCPCS/CPT code will be denied.
In this case, the MUE for CPT code 66761 is 1. You billed 2 units of this code, exceeding the MUE. Based on
this information, we decided that Medicare rules for coverage of the services provided have not been met.
Therefore, we decided that the Plan does not have to pay for the laser eye services provided on December 11,
2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the custodial care room and board provided September 1, 2019 to September 30, 2019.
You asked the Plan to pay for the custodial care. You say that you were waiting for an authorization for custodial care, but in the meantime the enrollee was participating in outpatient therapy. The Plan denied your request. The Plan says custodial care is not covered.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the custodial care have not been met. Therefore, we decided that the Plan does not have to pay for the custodial care room and board provided September 1, 2019 to September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve the AED.
You asked the Plan to pre-approve an AED, with integrated electrocardiogram analysis, garment type (K0606). You say that you need protection from sudden cardiac death. The Plan denied your request. The Plan says that criteria was not met.
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 an automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606). Our reviewer says that the requested item is considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a prior Myocardial Infarction, had a Coronary Artery Bypass Grafting (CABG) revascularization in February 2020, and has a Left Ventricular Ejection Fraction (LVEF) which can be as low as 35% as assessed by echo. This is an estimate of LV function as can be best obtained by transthoracic echo and the enrollee therefore meets criteria for a wearable defibrillator based on the LCD criteria. Medicare guidelines require 3 months' post revascularization procedure (in this case CABG) till LV function can be reassessed to see if it remains 35% or less and an implantable cardioverter defibrillator (ICD) would therefore be warranted. The enrollee therefore meets the LCD criteria listed above for the AED. In addition, due to the Covid-19 pandemic and the required cancellation of elective office visits and elective cardiac procedures (especially for these high Covid-19 virus risk individuals with cardiac disease) some additional time (beyond the standard 3 months) for continued utilization of the AED may be warranted in these special circumstances until this enrollee can have the LVEF safely be re-evaluated by echo in the office and the ICD procedure scheduled if needed. This additional time for utilization of the AED would be medically necessary and indicated until these follow-up procedures can be safely scheduled. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an automatic external defibrillator, with integrated electrocardiogram analysis, garment type (K0606) have been met. Therefore, we decided that the Plan has to pre-approve the AED garment.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on November 13,
2019.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says
the enrollee must receive care from in-network providers with the exception of emergency or urgent care,
dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network
provider, which requires prior authorization from the 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 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 a hospital outpatient clinic visit provided on November 13, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ear or pulse oximetry.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that ear/pulse oximetry is covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has shortness of breath. There is no history of respiratory disease. He had one resting room air oxygen saturation of 88 percent. The records do not support that the enrollee has a condition for which the requested services are covered. The services are not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve ear or pulse oximetry.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a drug test provided on November 13, 2019.
You asked the Plan to pay for the drug test. The Plan denied your request. The Plan says non-emergent, nonurgent
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 a drug test provided on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the processing fee provided from September 1, 2019 through
September 30, 2019.
You asked the Plan to pay for the processing fee. You say that you are requesting reimbursement of services
rendered. The Plan denied your request. The Plan says this is not a covered benefit.
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Review of the file show that you paid processing fees and your EOC states, the Plan does not reimburse for
initiation or registration fees, prorated fees, annual fees, account freeze fees, maintenance fees and any
miscellaneous fees or other penalties, equipment purchase or rental, any activities that take place in a private
residence or private club (including private golf / country clubs), food / supplements, any type of personal /
private training or lessons, player's club membership and walking or guided tour activities. Therefore, we
decided that the Plan does not have to pay for the processing fee provided from September 1, 2019 through
September 30, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on November 4, 2019.
You asked the Plan to pay for the physical therapy services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 physical therapy services provided on November 4, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a cleaning (D1110) and topical application of fluoride varnish (D1206) provided November 22, 2019.
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied your request. The Plan says dental services provided out-of-network are not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Topical application of fluoride varnish (D1206) is not a covered benefit, and a cleaning (D1110) is only a covered benefit when performed by an in-network provider. Therefore, we decided that the Plan does not have to pay for a cleaning (D1110) and topical application of fluoride varnish (D1206) provided November 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion supplies (A4221 and A4222) provided on March 2,
2019 through March 8, 2019.
You asked the Plan to pay for the infusion supplies. 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 include a
valid physician order, itemized shipping/billing invoice to indicate the specific supplies or proof of delivery.
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 physician order and
proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to
pay for infusion supplies (A4221 and A4222) provided on March 2, 2019 through March 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on December 6, 2019 by a non-contracted provider.
You asked the Plan to pay for the services. You say that when a provider is called to see a patient during their nursing home stay, their services would be covered by Medicare and if any authorization is needed the nursing home would be responsible for obtaining the authorization. The Plan denied your request. The Plan says the services were not authorized. The Plan states the provider did not contact the Health Plan for authorization of the 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 services provided to the enrollee on December 6, 2019 by a non-contracted provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
You asked the Plan to pre-approve the CGM. You say that it is felt that this would be a good option for the
enrollee to make it easier for her to do blood sugar checks. The Plan denied your request. The Plan says the
enrollee does not use multiple insulin injections and does not remember to do the four daily glucose checks
recommended by her doctor.
The Plan follows Medicare rules. Medicare rules say that therapeutic CGMs are covered for enrollees who
require blood sugar testing four or more times per day and three or more insulin injections.
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 CGM. Our reviewer says that the
requested CGM does not meet LCD criteria and is not shown to be otherwise reasonable and necessary for this
enrollee. Our physician reviewer found the enrollee has type 2 diabetes, as well as end-stage renal disease and a
failing memory. The enrollee is treated with insulin once nightly. She is supposed to test her blood sugar 4
times daily, but she does not always remember to do this. Her diet is not very good. It is documented that the
enrollee would like a CGM to avoid finger sticks on blood thinner. The LCD coverage criteria for a CGM have
not been met in this case. It is not clear that the requested CGM would be a better option for the enrollee than
the meter she has, given her memory loss. The documentation is insufficient to demonstrate that there are
unique circumstances in this case that support the medical necessity of the requested CGM.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have
to pre-approve a continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the eye surgery provided on October 21,
2019.
You asked the Plan to waive the copayment for the eye surgery. You say that you were told by the provider that
there would be no charge for the second surgery. 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 $325
copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory
surgical centers.
You have been asked to pay a $325 copayment for the eye surgery. The eye surgery falls within the "Outpatient
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit
category. This means that you have been asked to pay the correct amount based on your contract with the Plan.
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we
decided that the Plan does not have to waive the copayment for the eye surgery provided on October 21, 2019.
Your complaint about the provider's mistake 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on March 2, 2020 by an out of
network (OON) provider.
You asked the Plan to pay for physician services. You say that these services were medically necessary. 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. The Plan says that the referring provider is also out-of-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 physician services provided on March 2, 2020 by
an out of network (OON) provider.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for ambulance services provided September 27, 2019.
You asked the Plan to pay for the ambulance transport. You say that the service is a covered benefit and the claim is not being paid because the ambulance provider filed it incorrectly. The Plan denied your request. The Plan says that the claim shows that the ambulance pickup and drop-off locations were the same, so the service is not covered.
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. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. No medical records were provided. Specifically, without an ambulance run report, it cannot be determined if the ambulance pickup and drop-off locations were the same. The ambulance provider billed for mileage which indicates there was a different destination. Without the ambulance run report, the actual destination cannot be determined. Therefore, we decided that the Plan has to pay for ambulance services provided September 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the CT scan services coded 70450 provided on December 5, 2019.
You asked the Plan to pay for the CT scan services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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, we have confirmed that code 70450 for the CT scan services has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the CT scan services coded 70450 provided on December 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore testing provided on December 4, 2019.
You asked the Plan to pay for the testing services. You say that the test provides a validated strategy to reduce
the number of unnecessary prostate biopsies. The Plan denied your request. The Plan says published clinical
evidence does not support improved health outcomes.
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 rules say that the use of the 4Kscore test algorithm is noncovered,
regardless of how the test is being used. Based on this information, we decided that Medicare rules for
coverage have not been met. Therefore, we decided that the Plan does not have to pay for the 4Kscore testing
provided on December 4, 2019.