Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for ankle foot orthosis (L1971) provided on December 6, 2019.
You asked the Plan to pay for the ankle foot orthosis. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply code.
The Plan must follow Medicare rules. Medicare rules say that for any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ankle foot orthosis have not been met. Specifically, the record indicates that the Plan requested progress notes by the ordering physician along with documentation of the duration of the member's condition, clinical course (worsening or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results and previously purchased DME items related to the billed items. There is insufficient documentation to verify the supplies billed. Therefore, we decided that the Plan does not have to pay for ankle foot orthosis (L1971) provided on December 6, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalgan.You asked the Plan to pre-approve the Hyalgan. You say that you would like reconsideration as this drug is medically necessary.The Plan denied your request. The Plan says you do 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 Hyalgan. Our reviewer says that there is no documentation of a trial and failure of the Plan's preferred drugs. Our physician reviewer found the documentation does not support that the Plan's preferred drugs would likely be less effective or have adverse effects.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 Hyalgan have not been met.Therefore, we decided that the Plan does not have to pre-approve Hyalgan.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gel-One (J7326).
You asked the Plan to pre-approve the Gel-One. You say that you would like reconsideration because this drug is medically necessary. The Plan denied your request. The Plan says you do 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 Gel-One. Our reviewer says that the documentation submitted does not support that you have tried and failed any of the Plan's preferred alternatives. Our physician reviewer found the prescriber does not state why the alternatives required by the Plan (1) would not be as effective for you as the requested drug; and/or (2) would have adverse effects for you.
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 Gel-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit you had on January 27, 2020.You asked the Plan to waive the coinsurance. You say that you should only have a $10 copayment.The Plan denied your request. The Plan says you are responsible for the cost share.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% coinsurance for out-of-network PCP and specialist visits. Review of the file shows that you had an out-of-network office visit on January 27, 2020. The visit was allowed at $81.95. You have been asked to pay a 50% coinsurance for the visit, totaling $40.97. The visit falls within the out-of-network physician 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 coinsurance for the office visit you had on January 27, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the specialist office visits, the various outpatient diagnostic tests, the medical supply, and the Part B injection provided from August 1, 2019 to August 7, 2019. You asked the Plan to waive the cost share for the specialist office visit, the various outpatient diagnostic tests, the medical supply, and the Part B injection. You say that you were told your services were required prior to your surgery and would be covered by your insurance. The Plan denied your request. The Plan says you have been charged 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 $45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals, in a specialists office,  20% coinsurance for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility, 20% coinsurance for each Medicare-covered medical supply, and 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay a total of $313.70 for the specialist office visit, the various outpatient diagnostic tests, the medical supply, and the Part B injection. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The various outpatient diagnostic tests and the medical supply fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The Part B injection falls within the "Medicare Part B prescription drugs"benefit category.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the cost share for the specialist office visits, the various outpatient diagnostic tests, the medical supply, and the Part B injection provided from August 1, 2019 to August 7, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on June 21, 2019.You asked the Plan to pay for the services. You say that you felt better and didn't think it was necessary to be transported to the hospital.The Plan denied your request. The Plan says these services are not a covered 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 June 21, 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 for the ambulance services provided on June 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the circulating tumor cells (CTC) assay provided on June 25, 2019.You asked the Plan to pay for the testing. The Plan denied your request. The Plan says this is not a covered service.The Plan must follow Medicare rules. Medicare rules say that CTC testing is non-covered. We looked at the file and Medicare rules. The requested CTC assay is a non-covered service according to L35710. Based on this information, we decided that Medicare rules for coverage of the testing have not been met.Therefore, we decided that the Plan does not have to pay for the circulating tumor cells (CTC) assay provided on June 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for Vision services provided May 24, 2018 to June 25, 2019.
You asked the Plan to waive the cost-sharing for the vision services. You say that the cost-sharing should be waived because there was an error with the enrollee's prescription. The Plan denied your request. The Plan says the correct cost-sharing has been applied.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. We looked at the file and the Plan's rules. The correct copayments were applied per the plan contracts. Therefore, we decided that the Plan does not have to waive the cost-sharing for Vision services provided May 24, 2018 to June 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the labor charges provided on October 17, 2019.You asked the Plan to pay for the labor charges. The Plan denied your request. The Plan says that payment cannot be made to this provider.The Plan must follow Medicare rules. The rules state that Medicare payment cannot be made to a supplier who is not enrolled in the Medicare Program.The services were not provided by a provider who is enrolled in the Medicare program.Therefore, we decided that the Plan does not have to pay for the labor charges provided on October 17, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for adult sized disposable incontinence brief/diaper (T4521) and Single vitamin nos(A9152) purchased June 18, 2018 to July 17, 2019.You asked the Plan to pay for the incontinence supplies and vitamins. You say that you are appealing for reimbursement for incontinence pads and vitamins. It is not your fault that 60 days had lapsed it is the fault of the doctor's office who refused to process the claim timely.The Plan denied your request. The Plan says these items are not covered under the plan benefits.The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items.The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the vitamins is an OTC item.Therefore, we decided that the Plan does not have to pay for adult sized disposable incontinence brief/diaper (T4521) and Single vitamin nos (A9152) purchased June 18, 2018 to July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy (45385) provided on October 1, 2019.

You asked the Plan to waive the copayment for this service. You say that you are requesting a reconsideration of the Plan's denial for payment as you were told the service would be covered as preventative. The Plan denied your request. The Plan says the appropriate copayment has been applied to the service provided.

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 $210 copayment for each Medicare-covered outpatient admission to an ambulatory surgical center. 

You have been asked to pay a $210 copayment for this service. 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 diagnostic colonoscopy (45385) provided on October 1, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT code 27134 provided on June 15, 2019.
You asked the Plan to pay for CPT code 27134. You say that the medical records support the billing of CPT code 27134. The Plan denied your request. The Plan says the medical records do not support the billing of CPT code 27134.
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 27134 is Revision of total hip arthroplasty; both components, with or without autograft or allograft. 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 CPT code 27134. Our reviewer says that the medical records do not support the billing of CPT code 27134. Our physician reviewer found based on the documentation provided, the operative note documents the removal of a total hip and placement of an antibiotic spacer. The use of a more specific code is requested. The operative note does not clearly document revision total joint surgery with placement of new permanent components. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT code 27134 have not been met. Therefore, we decided that the Plan does not have to pay for CPT code 27134 provided on June 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on November 6, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says nonemergent,
non-urgent services with out-of-network providers require prior authorization.
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 physician's services provided on November 6, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on May 20, 2019 to September 25, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that these services were medically necessary. You say that you did not know you were out-of-network the member's specific plan. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer 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 physician services provided on May 20, 2019 to September 25, 2019 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 pneumatic compression device for the enrollee.
You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says there is no evidence of lymphedema extending onto the chest, trunk and/or belly that goes past the limits of a standard compression sleeve.
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 device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have physical exam evidence in the submitted documentation of lymphedema of the chest, trunk, or abdomen with unique characteristics that would indicate the segmented pump over a standard pump. The enrollee has not had an appropriate trial (4 weeks) of a standard pump. The enrollee does not meet criteria for an E0652 pneumatic compression device with accompanying lower garments.
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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wound care supplies provided on October 30, 2019 by an out of network provider.You asked the Plan to pay for the wound care supplies. You say that the Plan should pay this claim.The Plan denied your request. The Plan says you did not have prior authorization.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 supplies provided on October 30, 2019 by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the two removals of torus mandibularis, two alveoloplasties in conjunction with extractions, removable prosthodontic procedure, and ten extractions provided on January 2, 2020 and January 3, 2020.You asked the Plan to pay forthe removals of torus mandibularis, alveoloplasties, removable prosthodontic procedure, and extractions. You say that you got an infection in your jaw and needed to have all of your teeth removed. You also say that this was a medical problem, not only a dental problem.The Plan denied your request. The Plan says removal of torus mandibularis, alveoloplasty in conjunction with extractions, and unspecified removable prosthodontic procedure are not covered benefits. The Plan also says that your extractions benefit has been satisfied and the frequency limitation has been exceeded. 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, removal of torus mandibularis, alveoloplasty in conjunction with extractions, and unspecified removable prosthodontic procedure are not among those covered under this benefit. The contract also clearly states that extractions are limited to two procedures per calendar year. The record shows that you received twelve extractions on January 3, 2020, two of which were covered by the Plan at the in-network rate, and your extractions benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe two removals of torus mandibularis, two alveoloplasties in conjunction with extractions, removable prosthodontic procedure, and ten extractions provided on January 2, 2020 and January 3, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the prophylaxis (D1110) provided on July 30, 2019 by the out of network provider.You asked the Plan to reimburse you for the dental service. You say that you paid for the service in full. You say that you should only be responsible for the $40 copayment and be reimbursed the rest. You also say that the provider does not accept any insurance.The Plan denied your request. The Plan says you may be billed by the out of network provider for any amount greater than the payment made by the plan to the provider or any services not covered 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.Though the Plan offers a dental benefit in excess of Medicare coverage, you may be billed by the out of network provider for any amount greater than the payment made by the plan to the provider or any services not covered by the plan Therefore, we decided that the Plan does not have to reimburse you for the prophylaxis (D1110) provided on July 30, 2019 by the out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on February 4, 2020 by an out of network (OON) provider.
You asked the Plan to pay for skilled nursing services. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the rendering facility and provider are both out-of-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 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 skilled nursing services provided on February 4, 2020 by an out of network (OON) provider.