Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the DME provided on October 26, 2019.
You asked the Plan to reimburse you for the DME. The Plan denied your request. The Plan says to receive payment for covered Medicare items or services from either Medicare (in the case of an assigned claim) or a Medicare beneficiary (in the case of an unassigned claim), a provider or supplier must be enrolled in the Medicare program.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The file shows that you did not purchase the DME from a provider or a supplier that is enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have to reimburse you for DME provided on October 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi (J9173).
You asked the Plan to pre-approve Imfinzi. You say that Imfinzi is medically necessary. The Plan denied your request. The Plan says Imfinzi is not medically appropriate until the enrollee has had a treatment with standard chemotherapy.
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 Imfinzi. Our reviewer says that Imfinzi is not indicated at this time. Our physician reviewer found the enrollee's stage III non-small cell lung cancer has been treated to date with radiation alone without chemotherapy. Imfinzi is FDA approved for the treatment of unresectable stage III non-small cell lung cancer in adults whose disease has not progressed following concurrent platinum-based chemotherapy and radiation therapy. This enrollee has not received any chemotherapy to date. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Imfinzi have not been met. Therefore, we decided that the Plan does not have to pre-approve Imfinzi (J9173).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says rehab needs are not complex, and do not require an interdisciplinary approach, with multiple specialists to oversee rehab care.
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 enrollee is medically stable, with no evidence of need for supervision by a PMR physician. There is no need for acute rehab nursing care. The enrollee may benefit from PT and OT, but does not require an intensive therapy program. IRF admission is not medically necessary, based on current functional status and medical stability. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a MyoPro MotionG orthotic device (L8702).
You asked the Plan to pre-approve the orthotic device. You say that the MyoPro MotionG is medically necessary. The Plan denied your request. The Plan says the device is experimental for this use and not covered.
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 the orthotic device. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the advanced and custom components exceed the enrollee's needs. The device is considered investigational and therefore not supported by Medicare guidelines. 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 orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve a MyoPro MotionG orthotic device (L8702).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lipid panel rendered on November 29, 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 testing is not covered.
The Plan must follow Medicare rules. Medicare rules say that lipid testing is not covered as screening. We looked at the file and Medicare rules. The file shows that you received a lipid panel without any signs or symptoms of atherosclerotic heart disease. You did not have a condition for which this testing is covered by Medicare. The testing is considered screening in nature. 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 lipid panel rendered on November 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 5, 2019 to February 22, 2019.
You asked the Plan to pay for the SNF care. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. The file shows the claim was billed with Revenue Code 0022; however, total charges for revenue code 0022 should be zero. The claim was billed incorrectly per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from February 5, 2019 to February 22, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a hearing aid examination (92591), behind the ear binaural hearing aid (V5140), and hearing aid fitting/checking (V5011) provided on January 9, 2020 by the appealing provider.
You asked the Plan to pay for a hearing aid examination, behind the ear binaural hearing aid, and hearing aid fitting/checking. You say that you had obtained prior authorization from the plan and full payment should be rendered. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed correctly.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though a hearing aid examination, behind the ear binaural hearing aid, and hearing aid fitting/checking may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. Therefore, we decided that the Plan does not have to pay for a hearing aid examination (92591), behind the ear binaural hearing aid (V5140), and hearing aid fitting/checking (V5011) provided on January 9, 2020 by the appealing provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a naturopathic office visit (99215) provided on January 8, 2020.
You asked the Plan to pay for a naturopathic office visit. You say that this service was medically necessary. The Plan denied your request. The Plan says this service is not covered.
The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services. Therefore, we decided that the Plan does not have to pay for a naturopathic office visit (99215) provided on January 8, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided by on January
22, 2020.
You asked the Plan to waive the copayment for the colonoscopy. You say that you had a preventive
colonoscopy and are being billed a $350 copayment. The Plan denied your request. The Plan says you have
been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350
copayment for freestanding ambulatory surgical center.
You have been asked to pay a $350 copayment for the colonoscopy. The colonoscopy falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The medical record shows the colonoscopy was performed due to abdominal pain, a
change in bowel habits, and constipation which makes the colonoscopy diagnostic in nature.
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 colonoscopy provided on January 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional outpatient physical therapy services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient
therapy.
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 services. Our reviewer says that
skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's
condition. Our physician reviewer found your therapist has had ample time to address all her issues and to
establish a home exercise program. Additional sessions are not medically necessary after 10 months into
having a stroke with mild deficits. The services do not require the skills or direct supervision of a licensed
therapist. The prescribed exercise program is simple, repetitive and has not required hands-on care by a skilled
physical therapist. The records do not support the need for additional physical therapy visits. The requested
services are part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified
therapist are not required to establish, design and/or deliver a program to maintain the patient's current
condition or to prevent or slow further deterioration as a home exercise program has been addressed during the
sessions. The additional requested therapy visits are not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not
have to pre-approve additional outpatient physical therapy services.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy provided on October 21,
2019.
You asked the Plan to waive the copayment for the colonoscopy. You say that you should not be responsible
for the copayment because it is connected to a colonoscopy screening. 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 $150
copayment for each in-network Medicare-covered ambulatory surgical center visit.
You have been asked to pay a $150 copayment for the colonoscopy. The colonoscopy falls within the
"Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical
centers" benefit category. The record shows a diagnosis of ulcerative colitis which makes the colonoscopy
diagnostic in nature.
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 colonoscopy provided on October 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on November 15,
2019.
You asked the Plan to waive the copayment for a specialist visit. You say that you did not require anesthesia
and 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 $50
copayment for each specialist visit.
The medical records show that you received specialist services on November 15, 2019. Therefore, you are
responsible to pay the $50 copayment.
You have been asked to pay a $50 copayment for a specialist visit. A specialist visit 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 a specialist visit provided on November 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided to the
enrollee on September 28, 2019.
You asked the Plan to waive the copayment for the ambulance transport. The Plan denied your request. The
Plan says the claim processed 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 $300 copayment for one-way trip for emergency ambulance services and non-emergency
ambulance services.
The enrollee has been asked to pay a $300 copayment for the ambulance transport. The ambulance transport
falls within the one-way trip for emergency ambulance services and non-emergency ambulance services 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 copayment for the ambulance transport
provided to the enrollee on September 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 31, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for office visit. You say that this service was provided by a hospital house provider
and was medically necessary. The Plan denied your request. The Plan says the denial of payment for this
service is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for
service.
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 December 31,
2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a battery backup for the continuous positive airway
pressure (CPAP) machine (E1399).
You asked the Plan to pre-approve a battery backup for the CPAP machine. You say that the requested item is
necessary. The Plan denied your request. The Plan says the battery backup is not primarily medical in nature.
Therefore, coverage criteria has not been met.
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 battery backup for the continuous positive airway pressure
(CPAP) machine (E1399).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says it is not known if the
enrollee has a low vitamin D level.
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 Prolia. Our physician reviewer found
that the enrollee is post-menopausal with reported calcium and vitamin D supplementation. The records do not
offer a calcium or vitamin D level to support adequate supplementation, a review of lifestyle activities that
affect bone density, or a detailed list of trialed oral medications for the treatment of osteoporosis. Without this
documentation, Medicare guidelines and compendia guidelines are not supported. Therefore, the requested
drug is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to
pre-approve Prolia.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.
You asked the Plan to pre-approve Entyvio. The Plan denied your request. The Plan says the enrollee has not had prior therapy, contraindication, or intolerance to Stelara.
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 Entyvio. Our physician reviewer found that the enrollee has left sided colitis with rectal bleeding. The Plan requires a trial of Stelara before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drug. The documentation does not support that Stelara would likely be less effective, or would likely have adverse effects for the enrollee in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Entyvio have not been met. Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 17, 2019 by an out of
network (OON) provider.
You asked the Plan to pay for office visit. You say that you do not understand why this provider was not
covered. The Plan denied your request. The Plan says the denial of payment for these services is correct,
because this provider is out-of-network with the Plan and prior authorization was not obtained.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has 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 July 17, 2019 by
an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the ambulance transport provided on January 29, 2018.
You asked the Plan to waive the copay for the ambulance transport. The Plan denied your request. The Plan says that you are responsible for the copayment.
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 $265 copay for each covered, one-way ambulance trip by ground or water. You have been asked to pay a $255.33 copay for the ambulance transport. The ambulance transport falls within the covered, one-way ambulance trip by ground or water benefit category. This means that you have been asked to pay less than 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 copay for the ambulance transport provided on January 29, 2018.