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

We decided that the Plan does not have to pre-approve Supartz FX injections.
You asked the Plan to pre-approve Supartz FX. The Plan denied your request. The Plan says that they did not receive documentation or medical records 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 Supartz FX. Our reviewer says that that Supartz FX is not medically reasonable and necessary in this case. The provided medical records do not indicate that you have tried and failed the required drugs or that the Plan's required drugs would likely be less effective and/or likely have adverse effects for you. Our physician reviewer found that your condition does not meet criteria for Supartz FX. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX injections.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 51741 provided on June 27, 2019.
You asked the Plan to pay for CPT code 51741. You say that the medical records support the billing of CPT code 51741. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 51741.
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 51741 is Complex uroflowmetry (eg, calibrated electronic equipment). 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 CPT code 51741. Our reviewer says that the medical records do not support the billing of CPT code 51741. Our physician reviewer found National Correct Coding Initiative (NCCI) Policy Manual, chapter I states: Physicians must report services correctly. Procedures shall be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. Based on the documentation provided, CPT code 51741 is not supported. The medical record does not contain evidence that complex uroflowmetry was performed with calibrated electronic equipment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 51741 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 51741 provided on June 27, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits (CPT Code 92004) provided to the enrollee on May 29, 2019.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits.
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 plan did not authorize any services for a non-participating provider. The services are not considered urgent/emergent in nature. Prior authorization was not obtained as required under the plan benefits. Services rendered by nonparticipating providers, require prior authorization as outlined in the enrollees EOC. Therefore, we decided that the Plan does not have to pay for ophthalmological services: medical examination and evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits (CPT Code 92004) provided to the enrollee on May 29, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you$14.50 for a bifocal lens provided on August 9, 2019.You asked the Plan to reimburse youthe $14.50 for a bifocal lens. The Plan denied your request. The Plan says the bifocal lens is your financial responsibility.Medicare generally does not coverroutineeyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules.Based on this information, we decided that the Plan's rules for coverage of the $14.50 for a bifocal lens have not been met.Therefore, we decided that the Plan does not have to reimburse you$14.50 for abifocal lens provided on August 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Group 1 standard power wheelchair.You asked the Plan to pre-approvea Group 1 standard power wheelchair. You say that you need a scooter to move about outside of your home and your home is not wheelchair accessible.The Plan denied your request. The Plan says scooters are not covered for use only outside the home.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. The file does not show that your condition cannot be improved by a walker, cane or manual wheelchair or that you can safely operate the PMD being requested. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers power wheelchairsfor use only outside the home. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approvea Group 1 standard power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe psychological test and psychotherapy provided on June 19, 2019 and July 8, 2019.You asked the Plan to waive the copayments forthe psychological test and psychotherapy. You say that copayments are only owed when you meet with the doctor. You say that the office did not know a copayment was required.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). The enrollee's contract with the Plan clearly says that enrollees must pay a $45 copaymentfor diagnostic procedures and tests and a $40 copayment for group and individual sessions. The enrollee has been asked to pay a $45 copayment for the psychological test and a $40 copayment for psychotherapy. The psychological test falls within the "Outpatient diagnostic tests and therapeutic services supplies" benefit category. Psychotherapy falls within the "Outpatient mental health care" benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan.Therefore, we decided that the Plan does not have to waive the copayments forthe psychological test and psychotherapy provided on June 19, 2019and July 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (CPT Code 99308) provided to the enrollee by an out-of-network provider on April 19, 2019.
You asked the Plan to pay for the services. You say that the provider is not aware of the patient insurance when he sees the patient. The Plan denied your request. The Plan says the member does not have out-of-network benefits.
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 subsequent nursing facility care (CPT Code 99308) provided to the enrollee by an out-of-network provider on April 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator provided on August 29, 2019.
You asked the Plan to pay for the oxygen concentrator. You say that the enrollee did not notify of changes in health plan. The Plan denied your request. The Plan says there is no recent documentation supporting medical necessity.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the oxygen concentrator have not been met. The prescription is expired and there is no new clinical information supporting necessity. Therefore, we decided that the Plan does not have to pay for the oxygen concentrator provided on August 29, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided June 23, 2019 to June 28,
2019.
You asked the Plan to pay for acute inpatient hospital care. You say that services were medically necessary.
The Plan denied your request. The Plan says that the services could have been provided on an outpatient basis.
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 supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the medical records provided indicate that the admitting physician expected the enrollee's
admission to span two midnights. The enrollee presented to the emergency department for evaluation of
progressive shortness of breath over two days. She was noted to have wheezing and increased respiratory
effort. After treatments, the emergency provider noted her respiratory effort was improved. Care provided to
the enrollee was appropriate for inpatient.
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 been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided June 23, 2019 to June 28, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the sales tax for DME provided on July 13, 2019.
You asked the Plan to pay for the sales tax. You say that you are requesting reimbursement of services rendered. The Plan denied your request. The Plan says per CMS sales tax is not considered reimbursable.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the sales tax have not been met. Medicare regulations do not allow the Plan to reimburse separately for sales tax (S9999). Therefore, we decided that the Plan does not have to pay for the sales tax for DME provided on July 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by an out-of-network provider.You asked the Plan to pre-approvethe services. The Plan denied your request. The Plan says the services are available in-network.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 inthis 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. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided thatthe Plan does not have to pre-approvethe medical services to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the remote pacemaker evaluation provided on August 11, 2019.
You asked the Plan to waive the copayment for the remote pacemaker evaluation. You say that you have never been charged for the pacemaker evaluation before. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for specialty care physician. You have been asked to pay a $40 copayment for the remote pacemaker evaluation. The remote pacemaker evaluation falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the remote pacemaker evaluation provided on August 11, 2019.
Our decision is only about the August 11, 2019 service. If you have any questions about prior years billing, please contact the plan directly
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo (J9299).
You asked the Plan to pre-approve Opdivo. You say that this should be covered. The Plan denied your request. The Plan says this is related to a clinical trial you are enrolled in and therefore is the responsibility of Original Medicare.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services. In this case, you asked the Plan to pre-approve Opdivo as part of a clinical trial. The Plan does not cover routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to pre-approve Opdivo (J9299).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds (CPT Code K0813), for the enrollee.You asked the Plan to pre-approvethe DME. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The enrollee has history of cerebrovascular disease. There is no evidence that the enrollee of their family is unable to safely and efficiently propel a manual wheelchair and there is no evidence that the on-site evaluation of home environment was conducted for a motorized wheelchair use. The enrollee can be managed with a standard wheelchair.Therefore, we decided that the Plan does not have to pre-approvepower wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds (CPT Code K0813), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each (CPT Code E1354) and portable oxygen concentrator, rental (CPT Code E1392) purchased on May 29, 2019.You asked the Plan to pay forthe DME. You say that you are appealing for reconsideration of the denied charges.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. You have purchased an oxygen concentrator, the Inogen G3 High Flow package and would like reimbursement for the device and its delivery, totaling $2195. Your medical record shows that you need and have oxygen for home and bought this concentrator to improve your ability to get around. We are unable to approve your request. Medicare guidance states oxygen is a rental benefit and that purchased oxygen systems are noncovered. Your request for reimbursement for your Inogen G3 High Flow package is a noncovered benefit under Medicare and the Plan.Therefore, we decided that the Plan does not have to pay foroxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each (CPT Code E1354) and portable oxygen concentrator, rental (CPT Code E1392) purchased on May 29, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for biomarker testing services provided to the enrollee on August 4, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this testing is not currently recommended for identifying patients' likely response to FDA-approved drug therapy.
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 pay for the services. Our reviewer says that the services at issue in this case were not medically reasonable or necessary. Our physician reviewer found the enrollee is noted to have poorly differentiated squamous cell cancer of the lung (SCC). At the time of genetic testing, the enrollee had not received any treatment for her lung cancer. Testing directly related to SCC of the lung and for which corresponding treatments exist would be considered medically necessary and reasonable. Testing unrelated to SCC of the lung or for which no corresponding treatments exist is not considered medically necessary or reasonable. The provided genetic panel testing included testing unrelated to SCC of the lung and testing for which corresponding treatments do not exist. As such, the performance of the genetic panel test was not medically necessary or reasonable to diagnose, treat or otherwise manage the enrollee's condition. 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 services have not been met. Therefore, we decided that the Plan does not have to pay for biomarker testing services provided to the enrollee on August 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepower operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code K0800).You asked the Plan to pre-approvethe DME. You say that the durable medical equipment is medically necessary.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DMEhave not been met. You do not meet criteria for the power scooter as you are able to walk with a walker. Therefore, your request for a power scooter is denied at this time.Therefore, we decided that the Plan does not have to pre-approvepower operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds (CPT Code K0800).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not haveto pre-approvethe medical services to be provided by an out of network provider.You asked the Plan to pre-approvesuction lipectomy. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for this service 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 Planto pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services.