Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe medical services to be provided by out of network provider.You asked the Plan to pre-approve specialist services. You say that you would like to have this office visit approved.The Plan denied your request. The Plan says there are in-network providers available for these 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 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 the medical services to be provided by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveAranesp 40mcg/ml.You asked the Plan to pre-approveAranesp. You say that Aranesp is medically necessary.The Plan denied your request. The Plan says step therapy rules require a trial of plan preferred drugs 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 Aranesp. Our reviewer says that coverage rules have not been met. Our physician reviewer found there was no documented trial of the plan preferred drug, Retacrit, or any documentation show it would be contraindicated.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approveAranesp 40mcg/ml.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 16, 2019 by out of network provider.You asked the Plan to pay for physician services. You say that you would like this claim to be reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained for the services in question.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 forthe medical services provided on August 16, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Victoza (J3490).You asked the Plan to pre-approve Victoza. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says Victoza is a self-injected medication that does not meet Medicare criteria to be covered under the member's Medicare Part B 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 which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Victoza (J3490). Benefits for Victoza may be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
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-approvethe LTACH services. You say that the requested services are medically necessary.The Plan denied your request. The Plan says the enrollee can receive the care required at the current facility she is in. Therefore, coverage criteria has not been met.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 LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for chronic obstructive pulmonary disease(COPD) and congestive heart failure (CHF). The enrollee uses home oxygen and nightly bilevel positive airway pressure (BiPAP) at baseline. She required an increased amount of oxygen and more frequent BiPAP during the hospitalization. The enrollee expectedto continue home oxygen and noninvasive positive-pressure ventilation (NiPPV) at discharge. 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 (LTC) 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-approvelong term acute care hospital (LTACH) services.
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-approvespecialist office visit. You say that you need to see the doctor.The Plan denied your request. The Plan says this was a follow-up appointment. The Plan says that there are in-network providers for these 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 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-approvethe medical services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ultrasonic osteogenesis stimulator (E0760).You asked the Plan to pre-approvethe ultrasonic osteogenesis stimulator. You say that please reconsider coverage as this would be beneficial for the enrollee and the healing process.The Plan denied your request. The Plan says the use of this device for a failedfusion is not covered and the documentation fails to indicate that there has been 90 days between x-rays of the non-union fracture.The Plan must follow Medicare rules. The rules say that an electrical bone growth stimulator is covered for nonunion of long bone fractures. Nonunion of long bone fractures is considered to exist only when serial radiographs have confirmed that fracture healing has ceased for 3 or more months prior to starting treatment with the electrical bone growth stimulator. Serial radiographs must include a minimum of 2 sets of radiographs separated by a minimum of 90 days.In this case, nonunion of a long bone fracture is not considered to exist under Medicare rules. The file does not show that there were 2 or more serial radiographsseparated by 90 or more days confirming that healing had ceased.Therefore, we decided that the Plan does not have to pre-approveultrasonic osteogenesis stimulator (E0760).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay foran ankle-foot orthosis (L1971) provided to the enrollee on July 31, 2019.You asked the Plan to pay forthe orthosis. 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 saythat 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 foran ankle-foot orthosis (L1971) provided to the enrollee on July 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvevestibuloplasty surgery to prepare jaw for denture placement (40845).You asked the Plan to pre-approvevestibuloplasty surgery to prepare jaw for denture placement. You say that the services are necessary.The Plan denied your request. The Plan says the requested service is not a covered benefit.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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvevestibuloplasty surgery to prepare jaw for denture placement (40845).
Appeal type: Outpatient Therapies
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-approvephysical therapy. You say that you would like these services approved for payment.The Plan denied your request. The Plan says there are in-network providers available for the services that are being requested.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 issuein 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-approvethe medical services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe MRI (74181) provided on August 15, 2019.You asked the Plan to waive the copayment forthe MRI. You say that you feel you should not have to pay this cost share amount and you would like the plan to reconsider your request.The Plan denied your request. The Plan says you received an MRI on the date of service at issue in this appeal. The plan states the correct copayment has applied per your contract with the plan.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 $250 copayment for Outpatient diagnostic tests. We looked at the file, the Plan's contract and Medicare rules. The file shows that you received an MRI on August 15, 2019. You have been asked to pay a $250 copayment for the MRI. The MRI falls within the Outpatient diagnostictests 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 forthe MRI (74181) provided on August 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveDulera 200mcg/5mcg inhaler (J3535).You asked the Plan to pre-approveDulera 200mcg/5mcg inhaler. You say that the requested medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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 which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveDulera 200mcg/5mcg inhaler (J3535).Benefits for Dulera 200mcg/5mcg inhalermay 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 preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At leastfour weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652)
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forservices provided  on December 13, 2018.You asked the Plan to pay forthe ambulance services. You say that the service was medically necessary.The Plan denied your request. The Plan says the record shows the service was not medically necessary.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance services. Our reviewer says that the services were not medically necessary. Our physician reviewer found EMS personnel documented the enrollee was reporting anxiety.  Documented vital signs were non-concerning and physical exam noted to be unremarkable. Documentation does not support the enrollee's health was endangered iftransported to the hospital evaluation by other means.  Medical necessity is not supported. The denial is upheld.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 ambulance services have not been met.Therefore, we decided that the Plan does not have to pay forservices providedon December 13, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for diagnostic radiology services provided on May 24, 2019.You asked the Plan to waive the copayment fordiagnostic radiology services. You say that the plan would pay the bill. You say that you are living on social security, so any extra expenses is a burden.The Plan denied your request. The Plan says the correctcopayment has been 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 $250 copayment for outpatient diagnostic tests/diagnostic radiology services. You have been asked to pay $235.95 which is less than your copayment amount of $250 for diagnostic radiology services. Diagnostic radiology services fall within the outpatient diagnostic tests/diagnostic radiology services 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 fordiagnostic radiology services provided on May 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe wheelchair seat cushion (E2622) to be provided.You asked the Plan to pre-approvethe seat cushion. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says records do not show the enrollee has a wheelchair  for the seat cushion. Additional records were not received, therefore not medically necessarydue to insufficient documentation.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.  The records provided also state that the enrollee exercises by walking.We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the seat cushion have not been met.Therefore, we decided that the Plan does not have to pre-approvethe wheelchair seat cushion (E2622) to be provided.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance foreye surgery provided on August 8, 2019.You asked the Plan to waive the coinsurance foreye surgery. You say that you had to return for a second surgery. You say that you were not informed of a second copayment.The Plan denied your request. The Plan says the coinsurance 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 15% coinsurance for Medicare-covered surgery or other services at an in-network outpatient hospital or ambulatory surgical center.You have been asked to pay a total of $359.51 for eye surgery. Eye surgery falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" 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 coinsurance foreye surgery provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora wrist-hand orthosis (L3916) provided to the enrollee on December 28, 2018.You asked the Plan to pay forthe orthosis. 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 meansthat 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 fora wrist-hand orthosis (L3916) provided to the enrollee on December 28, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient hospital services by "the provider" on August 30, 2019.You asked the Plan to waive the copayment foroutpatient hospital services. You say that you say that you do not agree with these charges.The Plan denied your request. The Plan says the correct copayment has been 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 $325 copayment for outpatient hospital services/in-network/non-surgical visit in an outpatient clinic. You have been asked to pay $139.12 which is less than your copayment amount of $325 for outpatient hospital services. Outpatient hospital services fall within the outpatient hospital services/in-network/non-surgical visit in anoutpatient clinic 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 foroutpatient hospital services by "the provider" on August 30, 2019.