Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the skilled nursing facility (SNF) services provided May 2, 2019 to May 5,2019.You asked the Plan to waive the copayment forthe SNF services. You say thatyou were told by the plan that all days are covered until day 20 and you took her home on the 19thday.The Plan denied your request. The Plan says the enrollee did not start a new benefit period when admitted and therefore the correct cost share 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 $0 per day for days 1-20 and $160 per day for days 21-100 for Skilled nursing facility (SNF) care. You have been asked to pay $640. ($160x4=$640) for the SNF services. The SNF services falls within the Skilled nursing facility (SNF) care 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 skilled nursing facility (SNF) services provided May 2, 2019 to May 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 9, 2019 by the out of network provider.
You asked the Plan to pay for an office visit. 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 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 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 provided on October 9, 2019 by the out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the IRF admission is medically necessary as the member has suffered a severe stroke and their condition is worsening. The Plan denied your request. The Plan says necessary care may be rendered at a lower level.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 notconsidered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the member's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the member required the intensity of an IRF stay with close physician or nursing supervision. The member may benefit and participate in additional therapy of PT and OT but the member's functional status does not require this on an intensive rehabilitation facility therapy program level in an IRF.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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe hospital services provided on November 8, 2018.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says it is the providers responsibility to bill the primary health plan.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services provided until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay forthe hospital services provided on November 8, 2018.
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 the provider from August 2, 2019 to October 21, 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 by the provider from August 2, 2019 to October 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prolia injection.
You asked the Plan to pre-approve the Prolia. You say that the Prolia injection is medically necessary. The Plan
denied your request. The Plan says the member does not meet step therapy exception criteria.
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 the Prolia. Our reviewer says that the
record does not indicate that the member has tried and failed a trial of Zolendronic Acid. Our physician
reviewer found the documentation does not support that Zolendronic Acid would be less effective, and/or
would likely have adverse effects for the member.
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 Prolia have not been met. Therefore, we decided that the Plan does not have
to pre-approve a Prolia injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have topay foran office visit (99203), trimming skin lesions (11056), and an x-ray (73630) provided on August 23, 2019 by out of network provider.You asked the Plan to pay foran office visit, trimming skin lesions, and an x-ray. You say that the services provided were medically necessary.The Plan denied your request. The Plan says the non-urgent services were not authorized because the physician is a non-network provider with the member's health plan, and the member self-directed. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 foran office visit (99203), trimming skin lesions (11056), and an x-ray (73630) provided on August 23, 2019 by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an emergency room doctor advised you to go to a rehabilitation facility, and you cannot live on your own.The Plan denied your request. The Plan says the denial of authorization for IRF service is correct.The Plan must followMedicare 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 thePlan 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 complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that you have active medical conditions that require the intensity of an IRF stay with close physician or nursing supervision. While you may benefit from and participate in additional therapies of physical therapy and occupational therapy, you do not require this on an intensive rehabilitation therapy program level in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee from August 11, 2019 through October 30, 2019.You asked the Plan to pay forthe diabetic supplies. The Plan denied your request. The Plan says that there is no valid proof of delivery.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 itemsat issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered.Therefore, we decided that the Plan does not have to pay forthe diabetic supplies provided to the enrollee from August 11, 2019 through October 30, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray coded 73140 provided on September 5, 2019.
You asked the Plan to pay for the x-ray. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 73140 is radiologic examination, finger(s), minimum of 2 views. We find that CPT code 73140 is not supported in the medical record. Specifically, this code was billed without a required anatomical modifier. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray coded 73140 provided on September 5, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided on May 14, 2019.You asked the Plan to pay forthe lab services. The Plan denied your request. The Plan says stamped signatures are not an approved form of signature.The Plan must follow Medicare rules. The rules say that Medicare requires that services providedbe authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare's policies.We looked at the file and Medicare rules. In this case, there are insufficient records provided to show the results of this testing would be used to determine a specific diagnosis or determine a specific treatment strategy for disease or illness present in the enrollee at the time of service. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay forthe lab services provided on May 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care services provided on August 29, 2019 by an out of network provider.
You asked the Plan to pay for the wound care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 wound care services provided on August 29, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by the out of network provider.
You asked the Plan to pre-approve the outpatient visit. You say that the member's condition is progressing and they are seeking a second opinion. The Plan denied your request. The Plan says this provider is out-of-network and there are in-network providers available.
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 the out of network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF readmission.
You asked the Plan to pre-approve the SNF readmission. You say that these services will help the member to improve their quality of life. The Plan denied your request. The Plan says the member does not meet Medicare criteria for skilled nursing or skilled therapy.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 readmission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not require the necessary services on an inpatient basis in an SNF. 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 readmission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF readmission.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medication Euflexxa (J7323).
You asked the Plan to pre-approve this medication. You say that the patient has tried and failed Monovisc
however, the office does not use Orthovisc. The Plan denied your request. The Plan says the requested drug is
subject to step therapy. This requirement encourages you to try our preferred drug Orthovisc, which is just as
effective. We did not receive documentation or medical records supporting the medical necessity for a step
therapy exception.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve this medication. Our reviewer says that
the patient does not meet criteria for coverage of the medication Euflexxa. Our physician reviewer found the
patient has not tried and failed the required drug Orthovisc. The documentation does not support that Orthovisc
would likely be less effective, and/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 this medication have not been met. Therefore, we decided that the Plan does not
have to pre-approve the medication Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe medical services you provided to the enrollee on August 22, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysprecertification or authorization is absent.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 rendering 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 Plandoes not haveto pay forthe medical services you provided to the enrollee on August 22, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam (90214) provided by the eye doctor on October 23, 2019.
You asked the Plan to waive the copayment for the medical eye exam. You say that the eye doctor's office called you and said it was time for your check up and charged you $35 when they should not have and you want to be refunded. The Plan denied your request. The Plan says the claim was processed correctly and applied the correct member responsibility for the services.
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 $35 copayment for Medicare-covered eye exams to diagnose and treat diseases and conditions of the eyes. You have been asked to pay $35 copayment for the medical eye exam. The medical eye exam falls within the Vision care 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 medical eye exam (90214) provided on October 23, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device  provided by HNC Medical Supplies from June 19, 2019 to September 7, 2019.You asked the Plan to pay forthe 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 Plandenied 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 forthe glucose monitor, test strips, lancets, control solution, and lancet device  provided from June 19, 2019 to September 7, 2019