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

We decided that the Plan does not have to waive the copayment forthe office visit provided on November 15, 2019.You asked the Plan to waive the copayment forthe office visit. You say that the physician did not do anything for you.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 youmust pay a $20 copayment per in-network specialist visit. You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This meansthat 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 office visit provided on November 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlaboratory services provided to the enrollee on June 26, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says there are no symptoms or diagnosis that would be identified or modified by this testing.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 services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found in the case of this enrollee, hereditary cancer risk assessment testing was ordered and completed. No personal or direct family history of cancer was noted. Although "genetic susceptibility to other malignant neoplasm" was listed as a diagnosis, there was no objective evidence of such a classification. As the vast majority of cancers are not genetically linked, but rather environmentally and lifestyle related, the results of such genetic testing would not reasonably lead to any change in treatment change. There was insufficient evidence from the provided notes to justify this testing. Therefore, this request for genetic testing will be considered not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on June 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 24, 2019.You asked the Plan to pay for these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the testing is not covered.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on March 24, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided May 27, 2019 to May 31, 2019.
You asked the Plan to pay for the SNF services. You say that you feel that the plan should cover for SNF services. The Plan denied your request. The Plan says medical necessity criteria for SNF level of coverage were not met.
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 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided May 27, 2019 to May 31, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNFservices. The Plan denied your request. The Plan says that the enrollee's needs can be met at a lower level of care.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 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for continued SNF services.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Optimizer Smart IPG.
You asked the Plan to pre-approve the Optimizer Smart IPG. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this request does not meet the conditions for approval because Medicare does not consider this procedure to ever be reasonable and 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 your request, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Optimizer Smart IPG have not been met. Specifically, per Local Coverage Article: Billing and Coding: Non-Covered Services (A57642), this service is not covered due to being investigational/experimental, not proven effective or not reasonable and necessary. Therefore, we decided that the Plan does not have to pre-approve an Optimizer Smart IPG.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with codes A6549, A6531.You asked the Plan to pre-approvethe compression stockings. You say that you would like the stockings to aid in treatment for your leg swelling.The Plan denied your request. The Plan says gradient compression stockings A6549, A6531 are non-covered.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549, A6531 are noncovered because they do not meet the statutory definition of a surgical dressing. 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 codes A6549, A6531.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on September 9, 2019 by an OON provider.You asked the Plan to pay forthe domiciliary or rest home visit. You say that your physicians rendered servicesto this enrollee and should be compensated. You also say that the services were medically necessary.The Plan denied your request. The Plan says the services were rendered by a non-participating provider. The Plan also says that prior authorization was not obtained.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 urgentcare 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 atissue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forthe domiciliary or rest home visit provided on September 9, 2019 by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane injections for the enrollee.You asked the Plan to pre-approve Durolane. You say that this is medically necessary.The Plan denied your request. The Plan says that 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 Durolane. Our reviewer says that Durolane is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Monovisc (which is also Hyaluronic acid) or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Durolane.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Durolane have not been met.Therefore, we decided that the Plan does not have to pre-approve Durolane injections for the enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean implant/abutment supported fixed denture for edentulous arch (D6114).You asked the Plan to pre-approvethe implant/abutment supported fixed denture. You say that you know that implants are not covered and are asking for the Plan to cover the amount allowed for regular dentures to be applied to the implant dentures.The Plan denied your request. The Plan says this service is 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.Therefore, we decided that the Plan does not have to pre-approvean implant/abutment supported fixed denture for edentulous arch (D6114).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided on December 9, 2019.You asked the Plan to waive thecopayment fora CT scan. You say that you disagree with 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 enrolleesin clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay members must pay a $200 copayment for CT scans. You have been askedto pay a $200 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies 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 CT scan provided on December 9, 2019
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan does not have to pre-approve pneumatic compression device (E0652) and segmental pneumatic garment (E0668) to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the pneumatic compression device and garment. You say that you respectfully disagree with the denial and request an exception as this enrollee has been prescribed the Flexitouch pump for her unique condition.The Plan denied your request. The Plan says enrollee's must receive their services from an in-network provider.  The requested device is available from an in-network DME supplier.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve pneumatic compression device (E0652) and segmental pneumatic garment (E0668) to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve crutch substitute, lower leg platform (E0118).
You asked the Plan to pre-approve crutch substitute, lower leg platform. You say that you cannot use the wheelchair around the rooms in your home. The knee scooter is better and safer and allows you to get in and out of your chair and bathroom. The Plan denied your request. The Plan says this item is not covered under Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
While a crutch substitute may be appropriate in this case neither the plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve crutch substitute, lower leg platform (E0118).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crowns provided from August 7, 2019 to October 2, 2019.
You asked the Plan to pay for the crowns. You say that at the time of these services you were covered with the imbedded dental plan. The Plan denied your request. The Plan says this service is 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. Therefore, we decided that the Plan does not have to pay for the crowns provided from August 7, 2019 to October 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76770) provided on October 17, 2017.
You asked the Plan to pay for an ultrasound. You say that this was filed timely. The Plan denied your request. The Plan says this was filed more than a year after the date of service.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for an ultrasound was not filed until October 16, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for an ultrasound (76770) provided on October 17, 2017.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance provided on May 7, 2019.
You asked the Plan to pay for the periodontal maintenance. You say that this procedure has been a reimbursable expense for several years. The Plan denied your request. The Plan says this service is excluded from coverage.
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. The contract clearly states that periodontal cleanings are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance provided on May 7, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe breast ultrasound provided on May 14, 2019.You asked the Plan to waive the copayment forthe breast ultrasound. You say that you were not informed and did not agree to have the ultrasound. You say this should be included with the mammogram screening benefitThe 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 per day for Medicare-covered diagnostic radiology services. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $325 copayment for the ultrasound.You have been asked to pay a $114.95 copayment for the breast ultrasound. The breast ultrasound falls within the "Outpatient diagnostic tests and therapeutic servicesand supplies" benefit category. The record shows you received the ultrasound.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 breast ultrasound provided on May 14, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Rituximab.You asked the Plan to pre-approve Rituximab. You say that Rituximab is FDA approved for many malignant and non-malignant disorders, including lymphoproliferative diseases. The Plan denied your request. The Plan says that medical studies haven't proven that the drug is helpful for treatment of the members' health problemThe 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 Rituximab. Our reviewer says that Rituximab has been well documented in the literature for the treatment of the member's conditions. Our physician reviewer found Rituximab is safe and effective as well as reasonable and 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 Rituximab have been met. Therefore, we decided that the Plan has to pre-approve Rituximab. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an inpatient skilled nursing facility (SNF) admission.You askedthe Plan to pre-approveSNF care. You say that aninpatient skilled nursing facility admission is medically necessaryfor the enrollee.The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of an inpatient skilled nursing facility admission.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 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 SNF care. Our reviewer says thatinpatient skilled nursing facility care is not medically necessary. Our physician reviewer foundthe beneficiary does not require skilled nursing or therapy services on a daily basis. Additionally, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approvean inpatient skilled nursing facility (SNF) admission
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided March 1, 2019 to March 31, 2019.You asked the Plan to pay forthe SNF services. You say that you feel that the plan should cover for SNF service.The Plan denied your request. The Plan says the Medicare criteria for SNF level ofcoverage were not met.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 asked our physician reviewer to carefully review the case fileand apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing facility (SNF) services provided March 1, 2019 to March 31, 2019.