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

We decided that the Plan does not have to pay for the DecisionDX-Melanoma test provided on July 9, 2019.You asked the Plan to pay for the DecisionDX-Melanoma test. You say that the test was ordered by the enrollee's physician. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorizationMedicare 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 caseandthe ordering physician are notnetwork providers with the Plan. The Plan did not pre-approve the servicesat 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 DecisionDX-Melanoma test provided on July 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does nothave to pay for the medical services provided on July 31, 2019.You asked the Plan to pay for an outpatient hospital clinic visit (G0463). You say that you would like reconsideration as these services were medically necessary. The Plan denied your request. The Plan says non-urgent services should be from network providers who are contracted with the health plan and listed in the Provider Directory.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 31, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foroutpatient lab work provided by "the medical center". on August 12, 2019.You asked the Plan to waive the copayment foroutpatient lab work. You say that this should only be a $5 copayment.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 $50 copayment for outpatient diagnostic tests/lab services/OPH. You have been asked to pay a $50 copayment for outpatient lab work."The medical center"  is a general acute care hospital; therefore, the correct copayment has been applied. Outpatient lab work falls within the outpatient diagnostic tests/lab services/OPH 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 waivethe copayment foroutpatient lab work provided by "the medical center" on August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on January 7, 2019.You asked the Plan to pay for the 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 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 for a shoulder-hand-wrist orthosis (L3960) provided to the enrollee on January 7, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided to the enrollee on August 29, 2019.You asked the Plan to pay forthe ambulance services. You say that this was an emergency and should be covered.The Plan denied your request. The Plan says that if there is no transport, there is no benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on August 29, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services provided to the enrollee on August 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe AMD genetic testing (81401 and 81479) provided on July 18, 2019.You asked the Plan to pay forthe AMD genetic testing. You say that the AMD genetic testing provided was medically necessary.The Plan denied your request. The Plan says the AMD genetic testing provided was not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the AMD genetic testing. Our reviewer says that the AMD genetic testing provided was not medically necessary. Our physician reviewer found the enrollee is with diagnoses of Nonexudative age-related maculardegeneration of the right and left eyes, intermediate dry stage. The evidence that genetic testing can assist in tailoring AMD treatment is not definitive. Therefore, the AMD genetic testing provided was not medically necessary in this case.We looked atthis physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the AMD genetic testing have not been met.Therefore, we decided that the Plan does not have to pay forthe AMD genetic testing (81401 and 81479) provided on July 18, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on March 21, 2019.You asked the Plan to pay forthe orthoses. 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 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 arelikewise noncovered.Therefore, we decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1851, L2397) provided to the enrollee on March 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible foran office visit provided by "the doctor" on October 4, 2019.You asked the Plan to waive the deductible foran office visit. You say that you should only owe a $45copayment.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $750 deductible for out-of-network physician/practitioner services, including doctor's office visits. You had an office visit with an out-of-network provider on October 4, 2019. Therefore, you are responsible topay your share of the out-of-network cost-sharing charges. The record shows that you had paid $0 toward the $750 deductible. Therefore, you are responsible to pay the allowed amount of $168.99.The item or service you asked the Plan to waive the deductible for falls within the benefit category physician/practitioner services, including doctor's office visits. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for out-of-network physician/practitionerservices, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time an office visit was received on October 4, 2019.Therefore, we decided that the Plan does not have to waive the deductible foran office visit provided by "the doctor" on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora hearing test provided on July 30, 2019.You asked the Plan to waive the copayment fora hearing test. You say that you disagree with the charges.ThePlan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $35 copayment for hearing services. You have been asked to pay a $35 copayment for a hearing test. A hearing test falls within the hearing 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 fora hearing test provided on July 30, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to waive the copayment forthe office visit provided on October 28, 2019.You asked the Plan to waive the copayment forthe office visit. Yousay that this was your annual physical exam and there should be no charge. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.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 did not submit medical records to support this was an office visit and not an annual physical. Therefore, the plan has not shown that the copayment amount you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to waive the copayment forthe office visit provided on October 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe home infusion therapy (HIT) services provided from July 28, 2019 to August 4, 2019 billed with code S9328.You asked the Planto pay forthe HIT services. You say that this is a valid code according to the CMS website and no other code has been provided to bill for these services.The Plandenied your request. The Plansaysthis code is not payable by Medicare.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.CPT code S9328 has a status indicator of "I", meaning that it is invalid for Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the HIT services have not been met.Therefore, we decided that the Plandoes not haveto pay forthe home infusion therapy (HIT) services provided from July 28, 2019 to August 4, 2019 billed with code S9328
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on April 18, 2019.You asked the Plan to pay forthe services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services were not authorized.Medicare rules say that plans can require enrollees to get care fromnetwork 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 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 forthe medical services provided by an out-of-network provider on April 18, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ambulance transport provided on September 1, 2019.You asked the Plan to waive the copaymentforthe ambulance transport. You say that you've never had to pay $300 for one trip. You say that this bill is way too high.The Plan denied your request. The Plan says the copayment 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 a $300 copayment for each separate Medicare-covered, one-way, ambulance service.You have been asked to pay a $300 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance 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 forthe ambulance transport provided on September 1, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveEylea (aflibercept) injections.You asked the Planto pre-approvethe Eylea injections. You say that the enrollee has already tried Lucentis which left recurring fluid. It is the best option to change treatment to Eylea.The Plandenied your request. The Plansaysthere has been no trial of Avastin which is required prior to Eylea treatment.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 Eylea injections. Our reviewer says that the requested Eylea injections are not considered reasonable and necessary based on step therapy criteria. Our physician reviewer found the enrollee is a male with exudative age-related macular degeneration in the right eye with active choroidal neovascularization. He has tried and failed Lucentis but there has been no trial of the preferred drug Avastin. The documentation does not support that Avastin (Bevacizumab) 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 the Eylea injections have not been met.Therefore, we decided that the Plandoes not haveto pre-approveEylea (aflibercept) injections.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveSoliris for the enrollee.You asked the Plan to pre-approveSoliris. You say that this drug is highly effect for generalized myasthenia gravis.The Plan denied your request. The Plan says that that the enrollee's myasthenia gravis is controlled with the current treatment regimen and there is no specific need for the additional substitution of Solaris.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 Soliris. Our reviewer says that Soliris is medically reasonable and necessaryfor the enrollee in this case. In this case the patient is noted to have AchR antibody positive myasthenia gravis. Soliris has been approved by the FDA for use in this specific diagnosis/condition. This would support that the requested drug is medically reasonable and otherwise safe and effective for use in the patient's condition. While it is noted that the requested drug has never been studied for concurrent use with rituximab for myasthenia gravis--there is not a reason to suspect that there would be any clinical determent from the concurrent use of the drugs. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Soliris.We looked at this physician's review, the file, and Medicare rules. Based on this information, wedecided that Medicare rules for coverage of Soliris have been met.Therefore, we decided that the Plan has to pre-approveSoliris for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe paramedic intercept services.You asked the Plan to pay forthe paramedic intercept services. You say that that the paramedic intercept services were medically necessary. You also say that the ambulance company where you live does not provide paramedic services, and if you had not received paramedic services your health would have been compromised.The Plan denied your request. The Plan says this item is not a covered benefit.The rules say that Medicare pays for advanced life support (ALS) paramedic intercept services only when the servicesare furnished in a rural area. The paramedic intercept services at issue in this appeal were not furnished in a rural area.Therefore, we decided that the Plan does not have to pay forthe paramedic intercept services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Vertiflex procedure (22869, 22870, and 01992).You asked the Plan to pre-approvea Vertiflex procedure (22869, 22870, and 01992). You say that the requested Vertiflex procedure is medically necessary.The Plan denied your request. The Plan says the requested Vertiflex procedure is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve a Vertiflex procedure (22869, 22870, and 01992). Our reviewer says that the requested Vertiflex procedure is not medically necessary. Our physician reviewer found this enrollee has chronic low back pain with spinal stenosis. The enrollee is taking opiates for pain. The request is for interspinous spacer.  This is an experimental/investigational device. Therefore, the request is considered not medically reasonable or necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex procedure (22869, 22870, and 01992) have not been met.Therefore, we decided that the Plan does not have to pre-approvea Vertiflex procedure (22869, 22870, and 01992).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approveRepetitive Transcranial Magnetic Stimulation (rTMS) treatments.You asked the Plan to pre-approvethe rTMS treatments. You say that the rTMS treatment is medically necessary.The Plan denied your request. The Plan says coverage rules have not been met.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the rTMS treatments. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not meet the criteria for Repetitive Transcranial Magnetic Stimulation (rTMS) as the use of this procedure is considered experimental for the diagnosis she possesses.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 rTMS treatments have not been met.Therefore, we decided that the Plan does not have to pre-approveRepetitive Transcranial Magnetic Stimulation (rTMS) treatments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe injection provided on July 31, 2019.You asked the Plan to waive the copayment forthe injection. You say that you were given the impression that there would not be any charge for the injection. You say if you had been told of the charge, you would not have gotten the injection. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a planmust 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay $138.38 which is 20% of the allowed amount for the injection. The allowed amount is $691.92. ($691.92 x 20% = $138.38). The injection falls within the "Medicare Part B prescription drugs" benefit category.This means that you havebeen 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 injection provided on July 31, 2019.