Persius/hicric huggingface dataset:
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided by an out of network (OON) provider.

You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that the services were medically necessary. 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 had network providers available who could have provided 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 psychiatric diagnostic evaluation provided 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 push-rim activated power assist system (E0986) and under seat carrier (K0108).

You asked the Plan to pre-approve a push-rim activated power assist system and under seat carrier. You say that these items are medically necessary. The Plan denied your request. The Plan says these services are not covered.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The rules also state that for equipment to be covered, it must be appropriate and needed for use inside the home. 

The under-seat carrier 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. In addition, the push-rim active power assist system is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.

Therefore, we decided that the Plan does not have to pre-approve a push-rim activated power assist system (E0986) and under seat carrier (K0108).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services provided to the enrollee and billed under code 73562.

You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says code 73562 denied because the diagnosis code(s) associated to it are mismatched to the procedure modifier (RT) on the claim. The Plan says that coding guidelines indicate it is not appropriate to report unspecified, left, right or bilateral diagnosis codes when the procedure modifier does not match the diagnosis code. The Plan states a corrected claim is required.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes and when required the appropriate modifier. In this case, this claim cannot be paid as billed due to the omission of the correct required modifier. Medicare billing criteria are not met. Therefore, we decided that the Plan does not have to pay for radiology services provided to the enrollee and billed under code 73562.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to you by an out-of-network provider.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 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 had network providers available who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided to you by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One.
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 step therapy requirement is not met.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has pain related to right knee osteoarthritis. She has failed conservative treatment. She has not tried and failed the Plan's required drugs, Orthovisc and Monovisc. The records do not show that the required drugs would be contraindicated or less effective; therefore, Synvisc-One is not reasonable or medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Uloric for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

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 Uloric for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services.

You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. 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 says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for nurse practitioner services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the routine eye exam you had on November 10, 2020.

You asked the Plan to pay for the eye exam. The Plan denied your request. The Plan says this requested exceeds the benefit limit.

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. The Plan covers one routine eye exam per year. 

We looked at the file and the Plan's rules. The records show that you received a covered routine eye exam on August 13, 2020. The Plan only covers one routine eye exam per year. The requested exam exceeds the benefit limit and is not covered.Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. Therefore, we decided that the Plan does not have to pay for the routine eye exam you had on November 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was submitted after the timely filing limit.

The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the services was not filed until October 7, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF care.

You asked the Plan to pre-approve the SNF care. You say that the enrollee needs SNF care because you are unable to care for the enrollee yourself. The Plan denied your request. The Plan says the record does not show that the enrollee requires daily skilled nursing or skilled therapy in a SNF setting. The Plan also says that the services the enrollee requires are called custodial care, and are not covered by the Plan.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the enrollee does not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that requires the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy needs that requires the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 

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 SNF care have not been met. Although the enrollee has skilled therapy needs, these needs are not on a daily basis. Therefore, we decided that the Plan does not have to pre-approve the SNF care.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan (J7321).

You asked the Plan to pre-approve Hyalgan. You say that you benefited from Hyalgan in the past. The Plan denied your request. The Plan says step therapy requirements have not been met.

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 Hyalgan. Our reviewer says that the criteria for coverage of Hyalgan have not been met. Our physician reviewer found the Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. In this case, the patient has not tried and failed the required drugs. There is no documentation provided indicating that the plan's required drugs would likely be less effective or 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 Hyalgan have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalgan (J7321).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tacrolimus 1 mg capsule.

You asked the Plan to pre-approve Tacrolimus. You say that the request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this drug is not covered under the enrollee's medical benefit.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Tacrolimus 1 mg capsule.

Benefits for Tacrolimus may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for non-hospice respite care provided to the enrollee from January 2, 2020, to January 31, 2020.

You asked the Plan to pay for this service. You say that the enrollee required this care for evaluation after a fall and to determine if she could be placed as she could no longer live alone. The Plan denied your request. The Plan says respite services are only covered when the enrollee is under the hospice election. The enrollee was not under the hospice benefit and the enrollee did not have prior authorization for these services.

The Plan must follow Medicare rules. Custodial care is not covered. The day of admission the provider requested prior authorization and coverage for this service. The Plan provided a copy of the Notice of Non-Coverage signed by the enrollee on January 2, 2020 which was presented to her at admission as notification this care would not be covered. In addition to signing the document, this notice reflects the following was checked " I want the care listed above, but do not bill Medicare. I understand that I may be billed now because I am responsible for payment. I cannot appeal because Medicare won't be billed." The enrollee was given written notice by the Plan and verbal notice by the provider that these services would not be covered by her insurance. The enrollee signed the notice provided on the day of admission and chose to stay. Therefore, we decided that the Plan does not have to pay for non-hospice respite care provided to the enrollee from January 2, 2020, to January 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a consultation with an out-of-network provider.

You asked the Plan to pre-approve a consultation. You say that there are risks and complexities associated with the proposed remedy and an outside opinion should be considered. The Plan denied your request. The Plan says 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 care that cannot be provided by network providers. 

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 consultation with an out-of-network provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the annual cardiovascular disease visit you had on November 6, 2020.
You asked the Plan to pay for the visit. The Plan denied your request. The Plan says that the benefit limit was exceeded.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan says that the services exceed the benefit limit. However, the Plan has not provided records showing that the services were previously provided. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the annual cardiovascular disease visit you had on November 6, 2020.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve myocardial perfusion imaging (78452).
You asked the Plan to pre-approve myocardial perfusion imaging. You say that this is medically necessary. The Plan denied your request. The Plan says this is not indicated.
The Plan must follow Medicare rules. Medicare rules say that tests performed unrelated to changes in a patient's signs or symptoms, or for immediate pre-operative evaluation will be denied as medically unnecessary. We looked at the file and Medicare rules. The submitted medical records do not show that the enrollee had had changes or symptoms that indicate this test is necessary. Based on this information, we decided that Medicare rules for coverage of myocardial perfusion imaging have not been met. Therefore, we decided that the Plan does not have to pre-approve myocardial perfusion imaging (78452).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 24, 2020.

You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the member must receive care from a network provider. In most cases, care received from an out-of-network provider will not be covered, with the following three exceptions: emergency care or urgently needed services, Medicare covered medical care that the providers in our network cannot provide, and dialysis services at a Medicare certified dialysis facility when you are temporarily outside the Plan's service area. A prior authorization is required if you are seeking non-emergency out-of-network care.

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 did not pre-approve the physician's services. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on November 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit.

You asked the Plan to waive the copayment for the specialist office visit. You say that that the provider did nothing, except talk to you. The Plan denied your request. The Plan says you have been asked to pay 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 visits for specialists.

You have been asked to pay a $40 copayment for the specialist office visit. The specialist office 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 the specialist office visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you believe this service should be covered. The Plan denied your request. The Plan says the treating provider opted out of Medicare. The Plan also says that charges incurred by Medicare opt out provider will not be reimbursed by the Plan.

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. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.

We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the problem focused limited oral evaluation have not been met. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Testopel.
You asked the Plan to pre-approve Testopel. You say that this drug is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says Testopel is not medically necessary and reasonable.
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 Testopel. Our reviewer says that Testopel is not medically necessary and reasonable for the enrollee. Our physician reviewer found there is insufficient information based upon the documentation provided to determine whether the requested drug is medically reasonable and necessary and safe and effective for the enrollee's condition. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Testopel have not been met. Therefore, we decided that the Plan does not have to pre-approve Testopel.