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

We decided that the Plan does not have to waive the copayment for the CT scan provided on December 3,
2018.
You asked the Plan to waive the copayment for the CT scan. You say that you were informed you have no
copayments. You say that the copayment should be voided. The Plan denied your request. The Plan says the
$50 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 per visit diagnostic radiological procedures (such scans as CT, SPECT, MRI, MRA, myelogram,
cystogram, ultrasound, and diagnostic nuclear scans).
You have been asked to pay a $50 copayment for the CT scan. The 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 for the CT scan provided on December 3, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for molecular pathology services provided on July 5, 2019. 
 
You asked the Plan to pay for the molecular pathology services. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain service. There is no medical necessity for an out-of-network provider, such as an urgent or emergency situation, that has been documented.  
 
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 and the referring provider are not network providers with the Plan. The Plan did not pre-approve the pathology services. 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 molecular pathology services provided on July 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel 50 mg/ml syringes.
You asked the Plan to pre-approve this medication. You say that the member has been on this medication and in low disease activity since at least October 21, 2009 without any adverse side effects. The Plan denied your request. The Plan says this medication is not covered under the Medicare Part B benefit and therefore, is not covered by the health 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Enbrel 50 mg/ml syringes.
Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 12, 2018 to
June 25, 2018.
You asked the Plan to pay for the skilled nursing services. You say that the services provided to the enrollee
were medically necessary. The Plan denied your request. The Plan says it does not appear that criteria for
continued SNF stay beyond June 11, 2018 were met. The Plan also says that the enrollee was ambulating
household distances with a front-wheeled walker and able to do all activities of daily living with a frontwheeled
walker at that time.
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 skilled nursing services. Our reviewer
says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the
enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment
of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the
specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily
skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 skilled nursing services have not been met. Therefore, we decided that the
Plan does not have to pay for the skilled nursing services provided from June 12, 2018 to June 25, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says the enrollee has reached the 100-day benefit limit. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from August 29, 2019 to January 7, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. the enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF for atleast 60 days in row.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen services provided on September 17, 2019 by out of network provider.
You asked the Plan to pay for the oxygen concentrator. You say that the enrollee wants to continue services with this provider. The Plan denied your request. The Plan says you did not have 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 oxygen services provided on September 17, 2019 by out of network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the wrist x-rays and cast application provided on May 21, 2019, May 28, 2019, June 4, 2019 and June 26, 2019.
You asked the Plan to waive the cost share for the wrist x-rays and cast application. You say that you met your deductible. You say that you should not be charged out-of-network or any copayments. The Plan denied your request. The Plan says the deductible for May 21, 2019 applied correctly. The Plan also says that the claims for the remaining dates reprocessed to only apply a $50 copayment.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $500. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost of your covered services. Your contract with the Plan says that you must pay a $100 copayment for basic radiological services at an in-network outpatient hospital. The item or service you asked the Plan to waive the cost share for falls within the "Outpatient diagnostic tests and therapeutic services and supplies" and "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $500 deductible applies to basic radiological services and outpatient surgery services. This cost sharing is a contractual obligation that had not been met at the time the x-ray and cast application were received on May 21, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for Myocardial Perfusion Imaging (78452, A9500, 93017, J2785) provided January 31, 2018
You asked the Plan to pay for the imaging services. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says that the claim denied due to "DO-PPG / Hospital Risk". The plan also states they failed to review the initial appeal request within the allowable time frame.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The information submitted by the plan only states that they failed to make a decision with the allowable time frame, and that the claim initially denied due to "DO-PPG / Hospital Risk". The plan fails to elaborate or explain the denial reason. The plan does not cite specific flaws with the submitted documentation or claim that would make it unpayable. Therefore, we decided that the Plan has to pay for Myocardial Perfusion Imaging (78452, A9500, 93017, J2785) provided January 31, 2018
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a mammogram provided on August 5, 2019.
You asked the Plan to waive the copayment for a mammogram. You say that the radiologist said the 3D mammogram was necessary and 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 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 $25 copayment for diagnostic procedures or tests. The record shows that you had a diagnostic mammogram on August 5, 2019. Therefore, you are responsible to pay the $25 copayment. You have been asked to pay a $25 copayment for a mammogram. A mammogram 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 a mammogram provided on August 5, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for IRF care has not been met.
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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but you do not appear to have the ability to tolerate this therapy on an intensive rehabilitation facility 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an injection of Zilretta.
You asked the Plan to pre-approve Zilretta. You say that you are appealing with medical records. The Plan
denied your request. The Plan says the denial of authorization for this drug is correct, because Zilretta is not
intended for repeat administration and the enrollee has already received a Zilretta injection.
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 Zilretta. Our reviewer says that the
enrollee does not meet the Medicare criteria for Zilretta. Our physician reviewer found according to the Food
and Drug Administration's (FDA's) prescribing information, Zilretta is not intended for repeat administration.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to
pre-approve an injection of Zilretta.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a low dose computerized tomography (LDCT) scan.
You asked the Plan to pre-approve the LDCT scan. The Plan denied your request. The Plan says the coverage criteria are not met.
The Plan follows Medicare rules. Medicare rules say that an LDCT can is covered when the above 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 the LDCT scan. Our reviewer says that the LDCT scan is not medically reasonable and necessary. Our physician reviewer found that although some of the criteria for lung cancer screening with LDCT have been met (age, currently smoking), the physician's statement reports the enrollee has smoked less than the required 30 or more pack-years, which does not qualify the enrollee for consideration for LDCT scan for screening purposes 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 LDCT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a low dose computerized tomography (LDCT) scan.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe Scout 4 Wheel Compact Travel Scooter purchased on June 27, 2019.You asked the Plan to reimburse you forthe scooter. You say that you cannot walk and you were not told you had to use an in-network provider so you ordered the scooter online.The Plan denied your request. The Plan says criteria for a scooter was not met and you did not request prior authorization.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or providerwho has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider has opted out of the Medicare program. The file shows that the providerentered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to reimburse you forthe Scout 4 Wheel Compact Travel Scooter purchasedon June 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe collection of venous blood by venipuncture (36415), a lipid panel (80061), and the measurement of a thyroid stimulating hormone (84443) provided on August 30, 2019 by the out of network provider "the doctor". You asked the Plan to pay forthe collection of venous blood by venipuncture, a lipid panel, and the measurement of a thyroid stimulating hormone. You say that you are appealing the claim payment denial for services rendered to the member on date of service August 30, 2019. Medical records will support the medical necessity and clinical justification of the appeal.The Plan denied your request. The Plan says there was no prior authorization for date of service August 30, 2019. The referring provider "the doctor" is anon-participating provider. The plan did not authorize any services. The services were not considered urgent/emergent in nature and there was no referral from a contracted 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 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-approvethe 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 collection of venous blood by venipuncture (36415), a lipid panel (80061), and the measurement of a thyroid stimulating hormone (84443) provided on August 30, 2019 by the out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Blepharoplasty of the left eyelid (15823).You asked the Plan topre-approvethis service. You say that you would like to improve the quality of your life as you have droopy eyelids that are causing vision impairment.The Plan denied your request. The Plan says the request for left eyelid blepharoplasty is deniedas you donot meet the criteria of the left eye margin reflux distanceof 3.0 mm. Additionally, there is a lack evidence in the photographs that you sufferadequate visual field defects in the left eye to meet criteria for medical necessity of the procedure.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 pre-approve this service. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found that you donot have evidence of a central "pseudo-margin reflux distance" of 2.0 mm or less, or redundant eyelid tissue predominantly medially or laterally that clearly obscures the line of sight in corresponding gaze.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met.Therefore, we decided that the Plan does not have to pre-approvea Blepharoplasty of the left eyelid (15823).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on August 2, 2019.
You asked the Plan to pay for the knee orthosis (L1851) and suspension sleeve (L2397). You say that the Plan should pay this claim. The Plan denied your request. The Plan says services were misrepresented.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on August 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge services rendered on August 23, 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 procedure code 99239 is not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 30 minutes. We find that CPT code 99239 is not supported in the medical record. Specifically, there is no documentation of more than 30 minutes of discharge services spent on the enrollee. 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 pay for the hospital discharge services rendered on August 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician's services providedon September 23, 2019.You asked the Plan to pay forthe physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approvethe 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 forphysician's services providedon September 23, 2019.