Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to the enrollee on October 8, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe out-of-network services. You say that the services were an extension of the enrollee's initial visit.The Plan denied your request. The Plan says there is no network deficiency for the 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 lab 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 out-of-network services.Therefore, we decided that the Plan does not have to pay forthe lab services provided to the enrollee on October 8, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to enrollee on July 8, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe out-of-network services. You say that you were not aware of the requirement of obtaining a prior authorization.The Plan denied your request. The Plan says services provided by non-participating providers are excluded.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 lab services at issue in this appeal. The Plan did not pre-approve the services at issue. Wefound no exception that would require the Plan to pay for these out-of-network services.Therefore, we decided that the Plan does not have to pay forthe lab services provided to the enrollee on July 8, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSpiriva for the enrollee.You asked the Plan to pre-approvethis drug. You say that this drug is medically necessary.The Plan denied your request. The Plan says that this is not covered under the member's contract under any normal circumstances.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-approveSpiriva for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe 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 forthe medical services provided on October 21, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe out-of-network services. You say that treatment was deemed appropriate and consistent with the standard of care.The Plan denied your request. The Plan says services from non-participating providers are not covered unless they are authorized before the services are provided.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 out-of-network services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on October 21, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

Wedecided that the Plan has to pre-approveAdakveo (J3590). You asked the Plan to pre-approveAdakveo. You say that this is necessary to prevent frequent crisis and hospitalizations.The Plan denied your request. The Plan says that this is not necessary because the enrollee has not experienced at least 2 vasoocclusive crises in the past twelve months.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective andotherwise 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 Adakveo. Our reviewer says that Adakveo is medically necessary in this case. Our physician reviewer found Crizanlizumab-tmca (crizanlizumab, Adakveo) is FDA approved for patients and is an option for individuals with sickle-cell disease who have acute vaso-occlusive pain episodes unresponsive to hydroxyurea. This patient is stated as having frequent pain crisis despite the use of hydroxyurea and has a narcotic on the list of medications. The use of Adakveo is reasonable and 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 Adakveo have been met.Therefore, we decided that the Plan has to pre-approveAdakveo (J3590).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: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is no need for an HMO exception.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 Plandoes not haveto pre-approvea referral to an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGleostine for the enrollee.You asked the Plan to pre-approvethis drug. You say that this is medicallynecessary.The Plan denied your request. The Plan says that self-administered drugs are not covered.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-approveGleostine for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee's medical status requires the intensity of an IRF stay with close physician or nursing supervision. While the enrollee may benefit from and participate in additional therapies of physical therapy and occupational therapy, the enrollee does not require this on an intensive rehabilitation therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe group psychotherapy (90853) provided on July 9, 2019. You asked the Plan to pay forthe group psychotherapy services. You say that services were medically necessary.The Plan denied your request. The Plan says there were in-network providers available that could have provided the services at issue. The services were not emergent or preauthorized.Medicarerules 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 forthe group psychotherapy (90853) provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora Hepatitis A vaccine (90632) provided on November 1, 2019.You asked the Plan to pay for the immunization. You say that this immunization was medically necessary and Hepatitis A is well documented in your region. The Plan denied your request. The Plansays the Hepatitis A vaccine is not covered by your Part B plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the immunization. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the immunization. Therefore, we decided that the Plan does not have to pay for a Hepatitis A vaccine (90632) provided on November 1, 2019. Benefits for the immunization may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora mammogram (77067, 77063) provided on October 2, 2019. You asked the Plan to pay forthe mammogram. You say that the mammogram was medically necessary due to inconclusive results on a previous screening mammogram.The Plan denied your request. The Plan says only one screening mammogram is covered for women ages 35 to 39.The Plan must follow Medicare rules. Medicare rules say that Medicare allows coverage of a single screening mammogram for women ages 35 to 39. We looked at the file and Medicare rules. The enrollee was 39 at the time of service and had a previous screening mammogram. Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met.Therefore, we decided that the Plan does not have to pay fora mammogram (77067, 77063) provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 26, 2019 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that this provider is closer to your home and due to your illness you were unable to travel farther.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 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 forthe medical services provided on September 26, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean exception to the 50 mile limit for routine transportation.You asked the Plan to pre-approveexceptions to supplemental benefits. The Plan denied your request. The Plan says that each one-way trip must not exceed 50 miles.Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits they are not required to do so. Medicare does not provide exceptions to supplemental benefits.Therefore, we decided that the Plan does not have to pre-approvean exception to the 50 mile limit for routine transportation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forPart B injections provided on September 14, 2018.You asked the Plan to waive the coinsurance forthe Part B injections. You say that you should not be responsible for the coinsurance because you were told you would only be responsible for the stress test 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 20% coinsurance for in-network chemotherapy drugs, infusion drugs, and all other drugs covered under Medicare Part B. You have been asked to pay a total of $96.44 for the Part B injections. The Part B injections fall within the "Medicare Part B prescription drugs" benefit category. See chart below.Date of ServiceServiceAllowed AmountCoinsuranceMember LiabilitySeptember 14, 2019Technetium injection$256.2020%$51.24September 14, 2019Regadenoson injection$226.0020%$45.20Total$96.44 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 forthe Part B injections provided on September 14, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay fora psychotherapy visit, 60 minutes (90837) provided on March 22, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe psychotherapy visit, 60 minutes. You say that the services were provided and payment should be rendered.The Plan denied your request. The Plansays prior authorization was not requested or received and the services were not emergent in nature. Therefore, coverage criteria has not been met.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 fora psychotherapy visit, 60 minutes (90837) provided on March 22, 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 medical services provided on September 3, 2019 by an out of network (OON) provider.You asked the Plan to pay forlaboratory testing. You say that you were under the impression that this treatment would still fall under your doctor's plan of care, and this cost is a hardship for you.The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and 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 topay 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 forthe medical services provided on September 3, 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 medical services provided on October 14, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe out-of-network services. You say that you went to your eye doctor where you were told you were covered.The Plan denied your request. The Plan says you must use network providers to get your medical care and 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 out-of-network services.Therefore, we decided that the Plan does not have to pay forthe medical services provided on October 14, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forcarpal tunnel surgery provided on November 15, 2019.You asked the Plan to waive the copayment forcarpal tunnel surgery. You say that you had surgery in an ambulatory surgery center. You say that you were billed $275 instead of $225.The Plan denied your request. The Plan says the copayment applied correctly.The rules say a planmust 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 $275 copayment for surgery services at an in-network outpatient hospital.You have been asked to pay a $275 copayment for carpal tunnel surgery. Carpal tunnel surgery falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that the surgery was performed by the hospital. 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 forcarpal tunnel surgery provided on November 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe Computed Tomograpgy (CT) scan of the thorax (71260, Q9967) provided on October 15, 2019. You asked the Plan to pay forthe CT scan. You say that the services were medically necessary.The Plan denied your request. The Plan says there were in-network providers that could have provided the services at issue. The services were not preauthorized 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 services at issue in this appeal. The Plan did not pre-approve the service 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 Computed Tomograpgy (CT) scan of the thorax (71260, Q9967) provided on October 15, 2019.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services provided to the enrollee on January 15, 2019.
You asked the Plan to pay for the ambulance services. You say that The Plan denied your request. The Plan
says that that no additional payment is due to because the member's auto insurance carrier paid more than the
plan's allowed amount.
The Plan must follow Medicare rules. The rules state that that Medicare secondary payment amounts are
determined by a formula and are the lowest of:
1) Excess of the actual charge minus the primary payment;
2) The amount Medicare would pay if the services were not covered by a primary payer;
3) The higher of the Medicare payment amount or the primary payers allowable charge minus the amount
actually paid by the primary payer.
The breakdown of Medicare secondary payment is as follows:
1) $734 (actual charge) minus $587.20 (amount paid by primary) equals $146.80
2) Amount Medicare would pay $424.31 times 0.8 equals $339.45 (this is the amount Original Medicare would
pay, the allowed times 80% coinsurance)
3) $734 (the higher between the Medicare amount and the primary payers allowable) minus 587.20 (the amount
the primary payer paid) equals $146.80.
Medicare will pay the lowest of these amounts. The lowest amount is $146.80. Therefore, we decided that the
Plan has to pay $146.80 for the ambulance services provided to the enrollee on January 15, 2019.