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

We decided that the Plan does not have to pre-approve medial branch blocks (MBBs) for the enrollee.
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 MBBs are 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 chronic neck pain. She has multilevel degenerative changes on magnetic resonance imaging (MRI). She has radicular pain and has not had trials of conservative therapy. The criteria for coverage are not met and the MBBs are therefore not reasonable or medically necessary at this time. 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 medial branch blocks (MBBs) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the collagenase, clostridium histolyticum injection or waive the copayment for the administration of the injection provided on November 19, 2019.You asked the Plan to waive the coinsurance for the collagenase, clostridium histolyticum injection and waive the copayment for the administration of the injection. The Plan denied your request. The Plan says that the claim processed 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 20% coinsurance for Medicare Part B prescription drugs and a $50 copayment for Physician/Practitioner services in a specialist's office. You have been asked to pay a 20% coinsurance for the collagenase, clostridium histolyticum injection and a $50 copayment for the administration of the injection. The collagenase, clostridium histolyticum injection falls within the Medicare Part B prescription drugs and the administration of the injection falls within the Physician/Practitioner services in a specialist's office benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance for the collagenase, clostridium histolyticum injection and waive the copayment for the administration of the injection provided on November 19, 2019.
Appeal type: Imaging
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 25, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 25, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from October 3, 2019 to October 30, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was submitted with an invalid Type of Bill code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, this claim has been submitted with an inappropriate Type of Bill code. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from October 3, 2019 to October 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zilretta for the enrollee.
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. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of left knee osteoarthritis treated with several injections of Zilretta. Review of the compendia does not outline the safety and efficacy of repeat injections with this medication. Zilretta is therefore not reasonable or medically necessary 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Zilretta for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a sleep study.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that a sleep study 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 submitted records show that you had a previous diagnosis of obstructive sleep apnea (OSA) and were reportedly on positive airway pressure (PAP) therapy. There is no further detail in the submitted records. You had a diagnostic sleep study on October 31, 2019 that confirmed mild OSA. The requested repeat sleep study is 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a sleep study.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Temazepam for enrollee.You asked the Plan to pre-approve Temazepam. The Plan denied your request. The Plan says it is a self-administered medication and not covered under your Part B plan.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 Temazepam for enrollee.Benefits for Temazepam 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on August 1, 2019 by an out of network (OON) provider.You asked the Plan to pay for specialist services. 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 there is no network deficiency for these services and alternate network providers were found.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 specialist services provided on August 1, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (97110, 97140, G0283) provided on December 23, 2019 to January 15, 2020 by an out of network (OON) provider.
You asked the Plan to pay for OON physical therapy services. You say that your doctor should have requested authorization. The Plan denied your request. The Plan says these services were not authorizaed.
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 physical therapy services (97110, 97140, G0283) provided on December 23, 2019 to January 15, 2020 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an ER visit and an inpatient hospital stay from December 7, 2019 to December 13, 2019.
You asked the Plan to waive the copayments for an ER visit and an inpatient hospital stay. You say that you feel that the charges are absurd. 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 $90 copayment for emergency care. Your contract with the Plan also clearly says that you must pay a $290 copayment for days 1-6 per admission for inpatient hospital care. You had an ER visit on December 7, 2019. Therefore, you are responsible to pay the $90 copayment. You had an inpatient hospital stay from December 7, 2019 to December 13, 2019. Therefore, you are responsible to pay a $290 copayment for days 1-6 (December 7, 2019 to December 12, 2019). $290 (copayment) x 6 (inpatient days) = $1,740. The total amount you owe is: $1,830.00.
You have been asked to pay the total copayment amount of $1,830.00 for an ER visit and an inpatient hospital stay. An ER visit falls within the emergency care benefit category. An inpatient hospital stay falls within the inpatient hospital care 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 copayments for an ER visit and an inpatient hospital stay from December 7, 2019 to December 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Monovisc injection, 1 dose every 180 days.You asked the Plan to pre-approve the Monovisc injection. You say that he enrollee is currently taking Tylenol, 325 mg, for his left knee pain. You also say that he must limit his NSAID use to short term as he is on several different medications for his Diabetes.The Plan denied your request the Plan says the Monovisc injection is not medically necessary. The Plan says that the information provided does not show that the policy requirements have been met.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Monovisc injection. Our reviewer says that the requested medication does not meet the criteria for coverage. Our physician reviewer found there is evidence that the enrollee is symptomatic. There is no documentation of the x-ray findings to support the clinical diagnosis of osteoarthritis. There is no evidence that other diagnoses require exclusion. The reviewer found that the enrollee is unable to tolerate NSAID and has failed simple analgesics. However, the reviewer also found that aspiration and a corticosteroid injection were performed on April 3, 2020 at the time of this request with no documentation of a failed or inadequate response. Therefore, the reviewer found that the enrollee has not fully met the Medicare LCD (L33767) criteria for visco supplementation at this time.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 Monovisc injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a Monovisc injection, 1 dose every 180 days.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the BLS emergency ambulance service IA0429) and ground mileage (A0425) provided January 25, 2019.
You asked the Plan to pay for the ambulance services. You say that this service is not a duplicate service. The enrollee was transported twice on the same day. Both were 911 calls and one was at 6:11 pm and the other at 12:45am. The Plan denied your request. The Plan says when multiple transports are billed with the same pick up zip codes, the provider must submit one claim with both transports.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code A0429 and A0425 is not supported in the medical record. Specifically, the records do not support two emergency transportation was provided as only one PCR was provided for this date of service. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for the BLS emergency ambulance service IA0429) and ground mileage (A0425) provided January 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab.You asked the Plan to pre-approve Rituximab. You say that Rituximab is medically necessary.The Plan denied your request. The Plan says Rituximab is not safe and effective for the enrollee's diagnosis.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Rituximab. Our reviewer says that the drug is not medically necessary. Our physician reviewer found this review relates to a request for intra-vitreal injections of Rituxan with Methotrexate. Per the FDA website, the FDA label for Rituxan specifies that it is to be given only as an intravenous infusion. None of the CMS approved compendia support the use of Rituxan for the enrollee's condition. The journal articles submitted by the prescriber were reviewed. None of them reflects the enrollee's clinical situation. They do not support the use of intra-vitreal injections for the enrollee's condition. This reviewer did not find any supportive citations in a PubMed search.The documentation does not support that Rituximab is medically reasonable and necessary for the enrollee. The documentation does not support that Rituximab is safe and effective 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 Rituximab have not been met.Therefore, we decided that the Plan does not have to pre-approve Rituximab.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to provide additional reimbursement for the oral device/appliance used to reduce upper airway collapsibility provided on December 10, 2019.You asked the Plan to provide additional reimbursement for the oral device/appliance. You say that you were referred to this provider by your doctor, and later found out this provider was out-of-network. You also say that this provider rejected the in-network agreement for payment.The Plan denied your request. The Plan says that they offered an in-network exception to the provider if they agreed to their single patient agreement at 100% of Medicare, but the provider refused because the provider would be unable to balance bill you. The Plan also says that you are able to see this provider using your out-of-network benefits as per your EOC, but in-network exception is denied.The Plan must follow Medicare rules. Medicare rules say that oral appliances used to treat OSA are covered under the DME benefit. The rules also say that the MAO must pay the non-contracting non-participating (non-par) DME supplier the difference between the enrollee's cost-sharing and the DME supplier's bill.We looked at the file and Medicare rules. Since this item was provided by a DME supplier who does not participate in Medicare and accept Medicare rates, the Plan is required to pay 50% based on the total billed amount. You are not required to pay more than the 50% coinsurance. Based on this information, we decided that Medicare rules for coverage of the oral device/appliance have been met.Therefore, we decided that the Plan has to provide additional reimbursement for the oral device/appliance used to reduce upper airway collapsibility provided on December 10, 2019.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelower eyelid blepharoplasty (15820).You asked the Plan to pre-approvelower eyelid blepharoplasty. You say that this is a necessary corrective surgery.The Plan denied your request. The Plan says this is cosmetic.The Plan follows Medicare rules. Medicare rules say that any procedure(s) involving blepharoplasty and billed to this contractor must be supported by documented patient complaints which justify functional surgery. This documentation must address the signsand symptoms commonly found in association with ptosis, pseudoptosis, blepharochalasis and/or dermatochalasis.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct indenying the request to pre-approve lower eyelid blepharoplasty. Our reviewer says that the Medicare coverage criteria for the requested procedure has not been met. Our physician reviewer found the enrollee's complaints are primarily cosmetic related to the lower lid fat prolapse. Surgical intervention is not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of lower eyelid blepharoplasty have not been met.Therefore, we decided that the Plan does not have to pre-approvelower eyelid blepharoplasty (15820)
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 November 4, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you do not believe you should be responsible for the copayment. You say you have limited income. 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 $50 copayment for specialist visits. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office 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 the specialist office visit provided on November 4, 2019.
Your complaint about the employee'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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided on August 27, 2019 by an out of network (OON) provider.
You asked the Plan to pay for radiology services. You say that these services were ordered by the facility. The Plan denied your request. The Plan says no prior authorization was 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 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 radiology services provided on August 27, 2019 by an out of network (OON) provider.