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

We decided that the Plan does not have to pay for an MRI provided on January 17, 2019 by the out of network
provider.
You asked the Plan to pay for an MRI. You say that you would like this claim reprocessed and approved for
payment. The Plan denied your request. The Plan says no prior authorization was 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 an MRI provided on January 17, 2019 by the out of
network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on September 18, 2019.You asked the Plan to reimburse you an additional amount for the eyeglasses. The Plan denied your request. The Plan says you were reimbursed the correct amount up to the Plan benefit allowance of $100.Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and 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. The file shows you were reimbursed the correct amount up to the Plan eyewear benefit allowance of $100. Therefore, we decided that the Plan does not have to reimburse you an additional amount for eyeglasses provided on September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Hemodialysis (90937) provided on June 3, 2019 through June 28, 2019.
You asked the Plan to pay for the Hemodialysis. You say that you would like reconsideration as these services were medically necessary. The Plan denied your request. The Plan says CPT code 90937 is not appropriate for the service billed.
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 90937 is not supported in the record. Specifically, CPT code 90999 is required for all bill types 72X. Based on this information, we decided that Medicare rules for coverage of the Hemodialysis have not been met. Therefore, we decided that the Plan does not have to pay for Hemodialysis (90937) provided on June 3, 2019 through June 28, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient hospital services provided April 29, 2019 to April 30, 2019. You asked the Plan to waive the copayment for the outpatient hospital services. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayments were applied.
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 Outpatient Hospital Observation, an $80 copayment for emergency room services and a $200 for advanced imaging services including CT scans. The enrollee has been asked to pay a $300 copayment for Outpatient Hospital Observation, an $80 copayment for Emergency Room services and a $200 for advanced imaging services including CT scans for the outpatient hospital services. 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 outpatient hospital services provided April 29, 2019 to April 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 17, 2019.
You asked the Plan to pay for the assembly and operation of pump with oxygenator or heat exchanger. You say that this was a mandatory service. The Plan denied your request. The Plan says payment of this service is included in the DRG payment.
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that CMS designates to be "inpatient-only" services. These services have an OPPS status indicator of "C" in the OPPS Addendum B and are listed together in Addendum E of each year's OPPS/ASC final rule.
The service at issue in this appeal was billed with CPT code 99190. This code is listed with a status indicator of "C" on Addendum B of the 2019 OPPS/ASC final rule. This means the service has been designated as "inpatient only", and therefore must be billed as part of an inpatient admission. Therefore, we decided that the Plan does not have to pay for the assembly and operation of pump with oxygenator or heat exchanger (99190) provided on September 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) that is out of the referral circle (OORC).
You asked the Plan to pre-approve the OORC SNF care. You say that you feel that the plan should allow the enrollee to go to the SNF that is closest to his home. The Plan denied your request. The Plan says the enrollee's referral circle includes at least two other SNFs which are within a reasonable distance to the enrollee's residence.
Medicare rules say that plans must make care accessible to enrollees. According to Medicare rules, care is considered accessible to an enrollee if contract providers are available within reasonable distance and travel time from the enrollee's home. The plan contract says that enrollees must use contract providers. The requested SNF is not part of the enrollee's referral circle. We were able to confirm that the Plan has contract providers within the referral circle located within reasonable distance and travel time from the enrollee's home who can provide the necessary services. Under Medicare rules, this means that contract providers are accessible to the enrollee. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) that is out of the referral circle (OORC).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for choking, in the setting of amyotrophic lateral sclerosis (ALS). The enrollee was already using a NIV and had a PEG tube prior to this hospitalization. The enrollee has received a tracheotomy and is on a ventilator. There is no expectation of ventilator liberation or decannulation. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested admission to a LTACH is not medically necessary. Our physician reviewer found based on the documentation provided, the enrollee is currently undergoing treatment at an acute care hospital (ACH) for progressive renal failure and an infected sacral ulcer. The enrollee is receiving hemodialysis and a prolonged course of antibiotics. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (72100) provided on July 2, 2019.
You asked the Plan to pay for an x-ray. You say that you were told services from this provider would be covered. The Plan denied your request. The Plan says this service is not covered when provided by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an x-ray (72100) provided on July 2, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab work provided on April 11, 2019 by out of network provider. You asked the Plan to pay for outpatient lab work. You say that you were unaware that the patient should have gone to a contracted laboratory for services.The Plan denied your request. The Plan says no prior authorization or referral was 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 notpre-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 outpatient lab work provided on April 11, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair (PWC) to be provided by out of network provider. You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are available from network providers.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 power wheelchair (PWC) to be provided by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic manipulative treatment (98940) or the office visit (99203) with the out of network provider.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial as you live by yourself and do not have a family member to assist with transportation. You also say that the facility is approximately seven blocks away from your home. The Plan denied your request. The Plan says the requested services should be provided by an in-network provider. Additionally, the Plan says there are network providers available who can provide the requested 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the chiropractic manipulative treatment (98940) or the office visit (99203) with the out of network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia.
You asked the Plan to pre-approve Prolia. You say that the enrollee is at high risk for fracture, does meet all Medicare guidelines, and cannot take oral medication. The Plan denied your request. The Plan says the denial of authorization for Prolia is correct, because the Plan require a trial of Zoledronic Acid before it will approve Prolia.
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 Prolia. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Zoledronic Acid. The records do not show that Zoledronic Acid 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Prolia.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mechanical traction therapy (97012) provided on August 26, 2019.
You asked the Plan to pay for the mechanical traction therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says mechanical traction therapy is not a Medicare covered benefit when rendered by a chiropractor.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for mechanical traction therapy (97012) provided on August 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora Monovisc Injection provided June 4, 2019 by "the doctor".You asked the Plan to waive the copayment forthe injection. You say that the Monoviscwas ineffective and the copayment should be reimbursed.The Plan denied your request. The Plan says the correct copayment was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Part B Drugs. You have been asked to pay a 20% coinsurance for the injection. The injection falls within the Part B Drugs 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 fora Monovisc Injection provided June 4, 2019 by "the doctor".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and
lancet device provided by HNC Medical Supplies from August 15, 2019 to November 3, 2019.

You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control
solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied
your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.

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 glucose
monitor, test strips, lancets, control solution, and lancet device provided by HNC Medical Supplies from
August 15, 2019 to November 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99214), supplies and materials provided by the physician beyond those usually included in the office visit or service (99070), and behavioral counseling (G0447) provided on April 16, 2019 by out of network provider.
You asked the Plan to pay for an office visit, supplies, and behavioral counseling. You say that prior authorization needed wasn't obtained in a timely manner but due to the patient's type of treatment the services were imperative and medically necessary. The Plan denied your request. The Plan says services from non-participating providers are not covered under the open access plan unless pre-authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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), supplies and materials provided by the physician beyond those usually included in the office visit or service (99070), and behavioral counseling (G0447) provided on April 16, 2019 by out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided by from August 15, 2019 to November 3, 2019.
You asked the Plan to pay for the glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
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 glucose monitor, test strips, lancets, control solution, and lancet device provided from August 15, 2019 to November 3, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction of tooth #15 provided on May 21, 2019.
You asked the Plan to pay for the extraction of tooth #15. You say that when you added dental insurance to your plan, you were told that dentures were covered. You also say that you would like to be reimbursed for the $2,400 you paid out of pocket, as you were told when you signed up for the dental insurance. The Plan denied your request. The Plan says this service was performed by a non-participating provider. The Plan also says that you exceeded the number of allowed extractions for the time period.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, extractions are limited to two procedures per calendar year and you must pay 50% coinsurance when the service is received by an in-network provider. The record shows that you received three extractions on May 21, 2019 from a non-participating provider. Two extractions were paid by the Plan at the in-network benefit rate and your extractions benefit was then exhausted. You are responsible for the full cost of the extraction of tooth #15. Therefore, we decided that the Plan does not have to pay for the extraction of tooth #15 provided on May 21, 2019.