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

We decided that the Plan does not have to pay for drug testing (G0480) provided on July 16, 2019
You asked the Plan to pay for drug testing. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service July 16, 2019. You are in disagreement on the decision denied due to missing prior authorization. You were not aware of the requirement of obtaining a prior authorization. The Plan denied your request. The Plan says the provider is a non-participating provider. The referring provider listed is a non-participating provider. Our plan did not authorize any services for a non-participating provider. The services are not considered urgent/emergent in nature. There is no referring provider listed. There are multiple in-network providers within 30 miles of the members residence that could have rendered the 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 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 drug testing (G0480) provided on July 16, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that you have other conditions and you need orthotics. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (36415 and 85610) provided on May 22, 2019.
You asked the Plan to pay for laboratory services. You say that this should be reprocessed for payment. The Plan denied your request. The Plan says payment for these services is the responsibility of Original Medicare.
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 laboratory services (36415 and 85610) provided on May 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for standard wheelchair, fixed full length arms, fixed or swing
away detachable footrests (CPT Code E1130) purchased, a non-participating Medicare provider, on April 25,
2019.
You asked the Plan to pay for the standard wheelchair. You say that you are requesting reimbursement of
services rendered. The Plan denied your request. The Plan says the Medicare rules have 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. Your
EOC clearly states, DME and related supplies is not covered out-of-network and you are responsible for the
entire cost. Therefore, we decided that the Plan does not have to pay for standard wheelchair, fixed full length
arms, fixed or swing away detachable footrests (CPT Code E1130) purchased, a non-participating Medicare
provider, on April 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the neck and magnetic resonance angiography (MRA) of the head.

You asked the Plan to pre-approve an MRI of the neck and an MRA of the head. You say that you would like this imaging done. The Plan denied your request. The Plan says these services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 an MRI of the neck and an MRA of the head. Our reviewer says that the provided medical records do not include support that the MRI or the MRA is medically reasonable and necessary. Our physician reviewer found that while the record shows that you have headaches and neck pain, you have had no clinical follow-up with regard to these issues with a medical provider documented since July 9, 2019. The requested imaging services have not been shown to be medically reasonable and 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 an MRI of the neck and an MRA of the head have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the neck and magnetic resonance angiography (MRA) of the head.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Procrit.
You asked the Plan to pre-approve Procrit. You say that the requested Procrit is medically necessary. The Plan denied your request. The Plan says the enrollee must try and fail the Plan's preferred drug, Retacrit first.
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 Procrit. Our reviewer says that the Plan's step therapy criteria have not been met. Our physician reviewer found the enrollee is with pancreatic cancer and chemotherapy induced anemia. Procrit is being requested. The provided medical records do not indicate that the enrollee has tried and failed the required drug, Retacrit first. The provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects 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 Procrit have not been met. Therefore, we decided that the Plan does not have to pre-approve Procrit.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 20, 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 an out-of-network 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 must 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 May 20, 2019 by
an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a specialist office visit to be provided by out of network provider
You asked the Plan to pre-approve a specialist office visit. You say that you would like these visits pre-approved. The Plan denied your request. The Plan says there is in-network providers available.
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 a specialist office visit
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve 8 acupuncture visits for the enrollee.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your
request. The Plan says that a re-evaluation of condition is needed.
The rules say that acupuncture services are not covered by Medicare. However, the Plan offers an acupuncture
benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan
covers acupuncture only when the services are medically necessary and reasonable.
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 visits. Our reviewer says that the
requested visits are medically reasonable and necessary. Our physician reviewer found the denial states that a
re-evaluation is needed before undertaking acupuncture and then says the re-evaluation is not necessary. These
two statements contradict one another. The request is therefore deemed medically reasonable and necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the visits have been met. Therefore, we decided that the Plan has to pre-approve
8 acupuncture visits for the enrollee.
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee needs a shower chair to avoid an
accident. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are
not primarily medical in nature.
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (71045) provided September 6, 2019 by the facility.
You asked the Plan to pay for the radiology services. You say that the service was a repeat service. The Plan
denied your request. The Plan says the claim as submitted is a duplicate of a claim previously paid.
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 71045 is not supported in the medical record. Specifically, the CPT code, modifiers,
provide and service date denote a claim that is a duplicate to claim 820192540060536 which was already paid.
Based on this information, we decided that Medicare rules for coverage of the radiology services have not been
met. Therefore, we decided that the Plan does not have to pay for radiology services (71045) provided
September 6, 2019 by the facility.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee by the facility on July 15, 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 claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered to enrollee by the facility on July 15, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the benefactor by the provider on September 10, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 laboratory services rendered to benefactor by provider on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 9, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) and a knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on July 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe portable oxygen concentrator provided on August 30, 2019 by out of network provider. You asked the Plan to pay forthe portable oxygen concentrator. You say that the Care Manager at the hospital said the concentrator was covered and required for you to fly homeand now you need it to go to the store and travel.The Plandenied your request. The Plan says you did not get prior authorization for the out-of-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 pay forcare 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 portable oxygen concentrator provided on August 30, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the acute inpatient hospital care provided from August 8, 2019 to August 10, 2019.
You asked the Plan to waive the copayment. You say that you are requesting reconsideration of the Plan's denial. The Plan denied your request. The Plan says the claim has been paid and the copayment has been 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 $225 copayment each day, for days 1-8 for each acute inpatient hospital admission. You have been asked to pay a $450 copayment for the acute inpatient hospital admission (225 x 2). 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 acute inpatient hospital care provided August 8, 2019 to August 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214) provided on September 9, 2019 by out of network provider.
You asked the Plan to pay for an office visit. You say that you are seeking a review and requesting the payment. The Plan denied your request. The Plan says the provider is a non-network provider with the member's health plan, and the member self-directed. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, 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 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 an office visit (99214) provided on September 9, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the general health panel rendered on June 25, 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 services are not covered.
The Plan must follow Medicare rules. The rules say that code 80050 (general health panel) is considered a non-covered code. You have requested payment for services billed under code 80050. Medicare does not cover or pay for services billed under this code. Therefore, we decided that the Plan does not have to pay for the general health panel rendered on June 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are non-covered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveMemantine 5-10mg Titration pack.You asked the Plan to pre-approveMemantine. You say that the medication is medically necessary.The Plan denied your request. The Plan says coverage for Memantine is not available under the Part B Medical benefit.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 whichare covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveMemantine 5-10mg Titration pack.Benefits for Memantinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Life Alert Emergency Response system.
You asked the Plan to pre-approve a Life Alert Emergency Response system. You say that you feel this is medically necessary. The Plan denied your request. The Plan says this item is not primarily medical in nature.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a Life Alert Emergency Response system.