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

We decided that the Plan does not have to pay for the ophthalmoscopy for each eye, and the eye exam provided on August 28, 2019 by an out of network (OON) provider.You asked the Plan to pay for the vision care services. You say that you rely on the facility's staff to obtain the necessary authorizations.The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan also says the services were not urgent or emergent.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 ophthalmoscopy for each eye, and the eye exam provided on August 28, 2019 by an out of network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for fixed wing air transport (A0430) provided on October 3, 2019.You asked the Plan to pay for fixed wing air transport. You say that the claim was submitted with the zip code message in Box 23 of CMS1500 "Pop-In No Zip". The enrollee was picked up from the cruise ship's medical ward in Port of Grand Turk, Turks and Caicos.The Plan denied your request. The Plan says this service was billed incorrectly. The claim is missing a valid pick up zip code. A corrected claim is needed for further review.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 A0430 is fixed wing air transport.We find that CPT code A0430 is not supported in the medical record. The claim was billed with a modifier of HH and is missing a valid pick up zip code.Based on this information, we decided that Medicare rules for coverage of fixed wing air transport have not been met.Therefore, we decided that the Plan does not have to pay for fixed wing air transport (A0430) provided on October 3, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for insulin provided on August 24, 2019.
You asked the Plan to waive the coinsurance for insulin. You say that you were informed there was zero cost. You say that the bill should be paid. The Plan denied your request. The Plan says the coinsurance applied correctly.
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 chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B. You have been asked to pay $1,153.96, which is 20% of the allowed amount for insulin. The allowed amount is $5,769.84 (20% x $5,769.84 = $1,153.96). Insulin 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 insulin provided on August 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided on September 4, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that this is your primary care physician and you should not be responsible for the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 $30 copayment for each specialist visit. The record shows that you had a visit with a specialist, not your primary care physician, on September 4, 2019. Therefore, you are responsible to pay the $30 copayment. You have been asked to pay a $30 copayment for a specialist visit. A specialist visitfalls within the physician/practitioner services, including doctor's office visits 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 fora specialist visit provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on July 1, 2019.You asked the Plan to waive the copayment for specialist visit. You say that you are appealing this charge.The Plan denied your request. The Plan says the copayment 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $30 copayment for specialist visit. You have been asked to pay $30 copayment for specialist visit. Specialist visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 office visit provided on July 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Androgel medication.
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary for the enrollee as he has a diagnosis of testicular hypofunction. The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Androgel medication.
Benefits for this medication 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: DME/ Orthotics
Decision: Partially Favorable

We decided that the Plan has to provide the CGM. We decided that the Plan does not have to providethe CGM from a non-plan provider. You asked the Plan to providethe CGM. You say that your fingers are black and blue from finger stick testing.The Plan says that supplies purchased through a durable medical equipment provider will not be covered.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.The Plan has failed to cover or arrange for the CGM.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a FreeStyle Libre CGM have been met.Therefore, we decided that the Planhas to providethe CGM.We also decided that the Plandoes not haveto providethe CGM through a non-plan provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc 850 for the enrollee.
You asked the Plan to pre-approve Genvisc. You say that the enrollee had prior treatment on Orthovisc, which didn't work. The Plan denied your request. The Plan says the enrollee has not tried the preferred drug, Monovisc.
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 Genvisc. Our physician reviewer found that the enrollee has bilateral primary osteoarthritis of the knees. The Plan requires a trial of Orthovisc and Monovisc before they will approve the requested drug. The documentation does not show that the enrollee has tried both of the plan-required drugs. The documentation does not support that Orthovisc and Monovisc would likely be less effective, or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc 850 for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549, 99242.You asked the Plan to pre-approve the compression stockings. You say that you need the compression garments to be used at night so you can transition to the firmer set during the day.The Plan denied your request. The Plan says compression stockings like these are non-reusable supply items, therefore are not covered.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549, 99242 are noncovered because they are non-reusable supply items. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549, 99242.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services rendered to the enrollee on July 23, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plansays the testing is not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test 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 forthe laboratory services rendered to the enrollee on July 23, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy (45385) provided on October 28, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a preventive service. The Plan denied your request. The Plan says the copayment applied correctly.
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 $200 copayment for outpatient surgery. You have been asked to pay a $200 copayment for a colonoscopy. The colonoscopy falls within the outpatient surgery benefit category. The record shows that you had a pre-operative diagnosis of personal history of colonic polyps. The record also shows that a polyp was removed during this procedure. This means that the service is considered diagnostic and not a preventive service with a $0 copayment. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a colonoscopy (45385) provided on October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a gym membership provided from April 17, 2015 to December 17, 2015.You asked the Plan to reimburse you for the gym membership. The Plan denied your request. The Plan says the claim was filed after the time limit.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 applyin this case. The Plan's rules for coverage of gym benefits have not been met because the claim was filed beyond the time limit. Therefore, we decided that the Plan does not have to reimburse you for a gym membership providedfrom April 17, 2015 to December 17, 2015.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that transfer to an LTACH is medically necessary.The Plan denied your request. The Plan says Medicare coverage criteria for transfer to an LTACH are not met.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 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. Consequently, the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee currently.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CT scan provided on September 5, 2019.You asked the Plan to pay forthe CT scan. You say that you added the GW modifier to indicated that the service is not related to the hospice diagnosis. The Plan denied your request. The Plan says the Medicare hospice benefits covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. The record shows proof of hospice election from June 14, 2019 to September 11, 2019. Therefore, we decided that the Plan does not have to pay forthe CT scan provided on September 5, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approvea low dose CT scan of the chest.You asked the Plan to pre-approvea low dose CT scan of the chest. You say that the requested low dose CT scan of the chest is medically necessary.The Plan denied your request. The Plan says that the requested low dose CT scan of the chest is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 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 a low dose CT scan of the chest. Our reviewer says that the requested low dose CT scan of the chest is medically necessary. Our physician reviewer found coverage criteria are met for alow-dose chest CT scan, for the purpose of lung cancer screening.  This enrollee is a current smoker with at least 30 pack-years of smoking history.  She meets criteria for lung cancer screening, in terms of age and smoking history.  Screening with chest CT has been shown in clinical trials to reduce mortality from lung cancer, is covered by Medicare, and is considered reasonable and medically necessary for this 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 a low dose CT scan of the chest have been met.Therefore, we decided that the Plan has to pre-approvea low dose CT scan of the chest.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At leastfour weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on October 1, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for an eye exam. You say that these services were provided while the enrollee
resided at the rehab center. The Plan denied your request. The Plan says no prior
authorization was obtained for these services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for an eye exam provided on October 1, 2019 by an
out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe eye refraction provided to the enrollee on October 21, 2019.You asked the Plan to pay forthe eye refraction. The Plan denied your request. The Plan says this service is only covered when provided by a plan provider.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when they are provided.We looked at the file and the Plan's rules. The eye refraction was provided to the enrollee.  Based on this information, we decided that the Plan's rules for coverage of the eye refraction have not been met.Therefore, we decided that the Plan does not have to pay forthe eye refraction provided to the enrollee on October 21, 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 July 16, 2019.
You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says the services were available 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 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 July 16, 2019.