Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz injection services.
You asked the Plan to pre-approve Supartz injection services. You say that the requested drug is medically necessary. You say that you do not want a knee replacement. The Plan denied your request. The Plan says they did not receive documentation supporting the medical necessity for a step therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 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 Supartz injection services. Our reviewer says that the criteria for coverage of Supartz injections have not been met. Our physician reviewer found the provided medical records do not indicate that the enrollee has tried and failed a trial of Orthovisc and Monovisc. The provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz injection services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forradiation therapy provided from March 28, 2019 to July 10, 2019.You asked the Plan to waive the coinsurance forradiation therapy. You say that you shouldn't have to pay this because the provider is in-network.The Plan denied your request. The Plan says you are responsible for the in-network 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 20% coinsurance for Medicare-covered therapeutic radiology services. You have been asked to pay a 20% coinsurance for radiation therapy. radiation therapy falls within the Medicare-covered therapeutic radiology services benefit category. This means that you have been asked to pay the correctamount 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 forradiation therapy provided from March 28, 2019 to July 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on December 2, 2019.You asked the Plan to waive the copayment for the specialist office visit. You say that you thought the visit was a part of your follow-up from surgery. You say you should not be responsible for the copayment. 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 $45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you were seen for a follow-up visit. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical procedure.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 specialist office visit provided on December 2, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelongterm acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that you would like the plan to reconsider their denialThe Plan denied your request. The Plan says the requested admission is not medically necessary.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 the enrollee's ongoing care needs include respiratory support with oxygen supplementation, surveillance laboratory studies, intravenous antibiotics, and therapy services. The documentation does not support that the enrollee in this case requires services at the LTACH that arenot available at the acute care hospital where the enrollee is currently receiving care. There are no required medical services identified that are available at the LTACH, that are not available at the current health care setting being offered by the health plan.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 beenmet.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 14, 2019.The enrollee asked the Plan to pay for the ambulance services. The enrollee felt okay after treatment and felt going to the hospital was not necessary.The Plan denied the 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 July 14, 2019. 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 provided on July 14, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe high frequency chest wall oscillation devices (HFCWOD).You asked the Plan to pre-approvethe HFCWOD. You say that the records should support the necessity of the service in dispute.The Plan denied your request. The Plan says the enrollee's diagnosis of severe COPD and chronic respiratory failure does not meet the Medicare coverage criteria.The Plan must follow Medicare rules. Medicare rules say that high frequency chest wall oscillation devices are covered only for patients with cystic fibrosis, bronchietasis, or certain neuromuscular diseases.The record does not show that the enrollee hascystic fibrosis, bronchiectasis, or a covered neuromuscular disease. This means that the enrollee does not have a medical condition for which a high frequency chest wall oscillation device can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvethe high frequency chest wall oscillation devices (HFCWOD).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PalinGen injections (Q4174).You asked the Plan to pre-approve PalinGen injections (Q4174). You say that the requested PalinGen injections are medically necessary.The Plan denied your request. The Plan says the requested PalinGen injections are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve PalinGen injections (Q4174). Our reviewer says that the requested PalinGen injections are not medically necessary. Our physician reviewer found the enrollee has bilateral shoulder pain. He injured his Right shoulder in an MVA 10 years ago. He had Right shoulder surgery 10 years ago. The enrollee had a steroid injection into the shoulder. The physician wants to inject amniotic fluid (PalinGen) into the shoulder joint. This is an experimental/investigational medication and 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 PalinGen injections (Q4174) have not been met.Therefore, we decided that the Plan does not have to pre-approvePalinGen injections (Q4174).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on October 25, 2019.You asked the Planto waive the copayment for an ambulance trip. You say that the member is having financial hardship. You say that the member would like this copayment waived. 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $325 copayment for ambulance services. The enrollee has been asked to pay a $325 copayment for an ambulance trip. an ambulance trip falls within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an ambulance trip provided by a participating provider on October 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve AccuCheck BG diabetic testing strips.

You asked the Plan to pre-approve AccuCheck BG testing strips. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for these supplies is correct, because these diabetic testing supplies are not a Plan-preferred brand and are not covered.

The Plan must follow Medicare rules. Medicare rules say that the Plan may specify brands and manufacturers as preferred and limit supply to only those preferred brands so long as the enrollee retains access to all medically necessary items. 

We looked at the file and Medicare rules. The requested diabetic testing strips are not a Plan-preferred brand, and the enrollee can use a Plan-preferred brand to obtain these supplies. Based on this information, we decided that Medicare rules for coverage of AccuCheck BG testing strips have not been met. Therefore, we decided that the Plan does not have to pre-approve AccuCheck BG diabetic testing strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve genicular nerve radio frequency ablation (64624).You asked the Plan to pre-approve the radio frequency ablation. You say that you would like reconsideration because this is a reimbursed service under Medicare.The Plan denied your request. The Plan says this procedure is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the radio frequency ablation. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is considered experimental or investigational at this point and the member is not part of a clinical trial.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 radiofrequency ablation have not been met.Therefore, we decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance ride provided on November 26, 2019.You asked the Plan to waive the copayment forthe ambulance ride. You say that you do not have the financial ability to make the copayment. 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 $225 copayment for each one-way Medicare-covered ground trip. You have been asked to pay a $225 copayment for the ambulance ride. The ambulance ride 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 forthe ambulance ride provided on November 26, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on October 29, 2019.You asked the Plan to pay forthe 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 forthe medical services provided to the enrollee by an out-of-network provider on October 29, 2019.
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 November 6, 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 November 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay foran oral exam received on October 17, 2019.You asked the Plan to pay forthe exam. You say that this was needed prior to a root canal, and the other exams were just for regular checkups.The Plan denied your request. The Plan says the plan only covers two oral examinations per year.Medicare generally does not cover dental services. However, thePlan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers two oral exams per year. The file shows that two oral exams were already received during the year -on January 28, 2019 and September 16, 2019. Based on this information, we decided that the Plan's rules for coverage of the exam have not been met.Therefore, we decided that the Plan does not have to pay foran oral exam received on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea new CPAP machine.You asked the Plan to pre-approvea CPAP machine. You say that the Plan requested documentation from youso you sent an order.The Plan denied your request. The Plan says the enrollee has a newly repaired CPAP machine.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.The file shows that the enrollee has a repaired CPAP machine. Therepaired CPAP machine serves the same purpose as anewCPAP machine.The Plan now says there was no request for a new CPAP machine. Therefore, we decided that the Plan does not have to pre-approvea new CPAP machine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehearing aids.You asked the Plan to pre-approvehearing aids. You say that you have severe hearing loss and needs hearing aids to assist you. You have never had an issue obtaining hearing aids.The Plan denied your request. The Plan says the requested service is not covered per the plan benefits.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only hearing aids are covered only if you are pregnant or reside in a nursing facility. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met.Therefore, we decided that the Plandoes not have to pre-approvehearing aids.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for an x-ray of the hip billed with CPT code 73521 for date of service November 19, 2019.
You asked the Plan to pay for the x-ray. You say that you have attached medical reports for both procedures that clearly indicate these were two separate services and that the Plan incorrectly bundled these services for payment. The Plan denied your request. The Plan says that two or more diagnosis codes associated to the CPT code in dispute are mismatched per the ICD-10-CM Official Guidelines for Coding and Reporting.
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. Specifically, the Plan states that some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. The Plan says that it is not appropriate to report unspecified, or left and right diagnosis codes when a more specific (e.g. bilateral) code is available. However, that language does not appear in the ICD-10 CM Official Guidelines. These cited guidelines which the Plan used to support their denial do not say that, if the enrollee has a bilateral condition, then it is not appropriate to use the two lateral diagnosis codes which were billed. While it may be better to use the M16.0 diagnosis code for bilateral osteoarthritis of the hip, there is nothing saying that the claim is not payable solely because the diagnosis codes are separated. While the Plan can deny the claim for a bilateral procedure without a bilateral diagnosis, upon appeal the provider can support that the service billed was provided. In this case, the documentation provided does support that the enrollee had a bilateral x-ray for which bilateral osteoarthritis was found. The Plan has not substantiated their denial reason. Therefore, we decided that the Plan has to pay for an x-ray of the hip billed with CPT code 73521 for date of service November 19, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a radiologic examination of the chest provided on November 5, 2019.You asked the Plan to pay for the radiologic examination of the chest. 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 servicesat 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 radiologic examination of the chest provided on November 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided on September 23, 2019.You asked the Plan to pay for the genetic testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services provided are not a covered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.Review of the file shows that the enrollee does not have a diagnosis of major depressive disorder. Therefore, the genetic testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the genetic testing provided on September 23, 2019.