Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to enrollee by an out-of-network provider from April 2, 2019, to June 27, 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 enrollee by an out-of-network provider from April 2, 2019, to June 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Predict Hereditary Cancer Risk Panel rendered to the enrollee on May 21, 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 screening tests are 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, the Predict Hereditary Cancer Risk Panel, was requested solely for screening
purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan
does not have to pay for the Predict Hereditary Cancer Risk Panel rendered to the enrollee on May 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 5, 2019.
You asked the Plan to pay for these services. You say that the Plan should pay this because your eyes were
irritated. The Plan denied your request. The Plan says that you are required to use network providers unless
there is an emergency.
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 office visit provided on August 5, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered to you from May 20, 2019 to July 1, 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 provider is not Medicare-certified.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. The file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the home health services rendered to you from May 20, 2019 to July 1, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation (D9310) and dental extraction (D7210) to be performed by an oral surgeon.
You asked the Plan to pre-approve a consultation and dental extraction to be performed by an oral surgeon. You say that the services are necessary. The Plan denied your request. The Plan says services provided by an oral surgeon are not covered.
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-approve a consultation (D9310) and dental extraction (D7210) to be performed by an oral surgeon.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for non-medical expenses incurred by you, while out of the area, from July 7, 2019 to July 18, 2019.
You asked the Plan to reimburse you for the non-medical expenses including taxi transportation, food, hotels, and airline fees. You say that the Plan should reimburse you for the expenses. The Plan denied your request. The Plan says non-medical expenses are not a covered benefit under any normal circumstance.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. We looked at the file and Medicare rules. Your expenses are non-medical and therefore not reimbursable. Based on this information, we decided that Medicare rules for coverage of non-medical expenses including taxi transportation, food, hotels, and airline fees. have not been met. Therefore, we decided that the Plan does not have to reimburse you for non-medical expenses incurred by you, while out of the area, from July 7, 2019 to July 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the lumbar sacral orthosis provided on July 30, 2019.
You asked the Plan to waive the coinsurance for the orthosis. The Plan denied your request. The Plan says that you are responsible for 20%.
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 Durable medical equipment (DME) and related supplies. You have been asked to pay a 20% coinsurance for the orthosis. The orthosis falls within the Durable medical equipment (DME) and related 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 coinsurance for the lumbar sacral orthosis provided on July 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D testing provided by  on August 15, 2019.
You asked the Plan to pay for lab test. You say that you are appealing with medical records to support the service billed. The Plan denied your request. The Plan says the denial of payment for this service is correct, because preventive vitamin assays are not a Medicare-covered benefit.
The Plan must follow Medicare rules. Medicare rules say that Medicare considered vitamin assay panels as screening procedures which are non-covered. Vitamin D testing is only covered for certain specific diagnoses, and if a covered diagnosis is not billed then payment will be automatically denied. We looked at the file and Medicare rules. This testing was not performed for any Medicare-covered diagnosis. Based on this information, we decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for Vitamin D testing provided  on August 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day/reader/flash monitoring system.

You asked the Plan to pre-approve a Freestyle Libre 14 Day/reader/flash monitoring system. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria for this item.

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.

We looked at the file and Medicare rules. Medicare states a CGM is covered if criteria above are met. Medicare states you must be insulin treated in order to meet criteria for a CGM. The file shows you are not insulin treated and do not meet criteria for a CGM. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre 14 Day/reader/flash monitoring system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 14 Day/reader/flash monitoring system.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve DUROLANE forthe enrollee. You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the step therapy requirement is not met.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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has a diagnosis of bilateral primary osteoarthritis of the knees. The plan requires a trial of Orthovisc and Monovisc and the records do not show that the enrollee has tried and failed these drugs. The records do not show that the required drugs would be less effective or contraindicated; therefore, DUROLANE is 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-approveDUROLANE for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 16, 2019 through March 18, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found no diagnosis was found, according to the records and the patient was stable. Although based on the documentation provided the treating physician was concerned about his chest pain and prior history of cardiovascular disease, there was insufficient acute findings or evidence of a cardiac or other condition which might need a prolonged management and workup which would last more than two midnights. Observation care could have been implemented for further workup and monitoring. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 16, 2019 through March 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hydrocodone/APAP tab 5-325mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is denied as a benefit exclusion.
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 Hydrocodone/APAP tab 5-325mg for the enrollee.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 12, 2019.
You asked the Plan to pay for the laboratory services. You say that you are requesting that this claim be reprocessed and paid at the in-network rate. You also say that you are the only service provider for this cell-free circulating tumor DNA test. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.
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. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the cervical multiple post collar provided on February 24, 2019.
You asked the Plan to pay for the cervical multiple post collar. You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Medicare rules say that the cervical multiple post collar should not be reported by a physician in a non-office setting.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate Place of Service code. We find that the place of service, global surgery modifier 78, is incorrect as it is not the place where the enrollee will primarily use the collar. Based on this information, we decided that Medicare rules for coverage of a cervical multiple post collar have not been met. The Plan requested a corrected claim with no success. Therefore, we decided that the Plan does not have to pay for the cervical multiple post collar provided on February 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BRCA 1 and 2 testing.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says there is no personal history of cancer.
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, the testing, is being 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 pre-approve BRCA 1 and 2 testing.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on September 20, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that this was one procedure. You say that you should only have one copayment. The Plan denied your request. The Plan says the copayments 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 $225 for each Medicare-covered diagnostic radiology service from an in-network provider. You have been asked to pay a $225 copayment for each CT scan. The total amount you owe is $450 ($225/scan x 2 scans = $450). The CT scans falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that two CT scans were performed, therefore a copayment applies to each scan. 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 CT scan provided on September 20, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by out of network provider.
You asked the Plan to pre-approve outpatient physical therapy. You say that this provider is highly recommended for the enrollee's treatment plan. The Plan denied your request. The Plan says the denial of authorization for these services is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.
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 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. 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 the medical services to be provided by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 21, 2019 by an out-of-network provider. You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit. 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 laboratory services provided on May 21, 2019 by the out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveSynvisc-One for the enrollee.You asked the Plan to pre-approveSynvisc-One. 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 Synvisc-One. Our reviewer says that Synvisc-One is not medically reasonable and necessary for the enrollee. The documentation does not support that the enrollee has tried and failed Orthovisc and Monovisc 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 the enrollee's condition does not meet step therapy criteria for Synvisc-One.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met.Therefore, we decided that thePlan does not have to pre-approveSynvisc-One for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray provided on February 20,
2019.
You asked the Plan to waive the copayment for the chest x-ray. You say that you don't understand why the cost
is so high. 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 $50
copayment for x-ray services in an outpatient hospital facility.
You have been asked to pay a $50 copayment for the chest x-ray. The chest x-ray 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 for the chest x-ray provided on February 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 12, 2019 to June 22,
2019 by an out-of-network provider.
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 services were rendered by a non-plan provider without prior authorization.
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 medical services provided on June 12, 2019 to
June 22, 2019 by an out-of-network provider.