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

We decided that the Plan does not have to waive the coinsurance fora ferric carboxymaltose injection(J1439) provided on September 9, 2020.You asked the Plan to waive the coinsurance foran injection. You say that you should not have to pay the coinsurance. The Plan denied your request. The Plan says the coinsurance was 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for injection. The services at issue fall 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 coinsurance fora ferric carboxymaltose injection(J1439) provided on September 9, 2020. Your complaint about the injection being unsuccessful is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on November 22, 2019, by
an out-of-network (OON) provider.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their
denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent
nor urgent and prior authorization was not obtained to provide 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 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 laboratory services provided on November 22,
2019, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99214) provided on August 28, 2020.You asked the Plan to pay foran office visit. You say that this should be covered.The Plan denied your request. The Plan says an explanation of benefits from your primary insurance has not been submitted.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 thebill 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 this claim to the primary insurance and has requested the explanation of benefits from the primary insurance. As the secondary insurer, the Plan cannot be held responsible for an office visit until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay foran office visit (99214) provided on August 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea power operated vehicle.You asked the Plan to pre-approvethe vehicle. You say that this is medically necessary.The Plan denied your request. The Plan says this equipment will be used outside of the home.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 vehicle. Our reviewer says that the requested vehicle is not medically reasonable or necessary. Our physician reviewer found it is not clear that your mobility deficit impairs participation in MRADLs in the home. The requested equipment is for use only outside of the home.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 vehicle have not been met.Therefore, we decided that the Plan does not have to pre-approvea power operated vehicle.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvebioimpedance spectroscopy imaging for the enrollee.You asked the Planto pre-approvethe imaging. You say that the enrollee is at a high risk of developing lymphedema, and this treatment is medically necessary.The Plandenied your request. The Plansaysthere is a lack of comparative medical trials that show the effect of bioimpedance on medical outcomes for the detection of lymphedema.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 imaging. Our reviewer says that the requested imaging is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 73 year old female who underwent ultrasound-guided core biopsy of the left breast on 10/30/20 showing signs of invasive ductal carcinoma grade II. BIS was requested to be used for screening for lymphadenopathy. Thistechnology is not yet developed to show more accuracy than serial arm circumference measurements or other low-cost alternative ways of screening for changes. Therefore, this request for BIS will be considered not 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 the imaging have not been met.Therefore, we decided that the Plandoes not haveto pre-approvebioimpedance spectroscopy imaging for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecontinued inpatient psychiatric care as of January 27, 2021.You asked the Plan to pre-approveinpatient psychiatric care. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for inpatient psychiatric care as of January 27, 2021 is correct.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric care. Our reviewer says that the enrollee does not meet the Medicare criteria for continued inpatient psychiatric care. Our physician reviewer found based upon review of the records provided, it was not expected this enrollee would improve in a reasonable period of time beyond January 26, 2021 as he was not showing any dangerousness to self or others, auditory or visual hallucinations, and without aggressive behaviors while not showing any acute threats of safety. It does not appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. It does not appear that the services beyond January 26, 2021 are reasonably expected or medically necessary to improve the enrollee's condition or for the purposes of diagnosis.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care have not been met.Therefore, we decided that the Plan does not have to pre-approvecontinued inpatient psychiatric care as of January 27, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular denture provided on September 24, 2020.
You asked the Plan to pay for the complete maxillary denture and complete mandibular denture. You say that you did not receive the false dentures. You also say that you were not satisfied with them. The Plan denied your request. The Plan says the benefits for these services have 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, complete dentures are limited to one upper complete and/or one lower complete denture every five years. The record shows that you received a complete maxillary denture and a complete mandibular denture on January 8, 2020, and your complete dentures benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the complete maxillary denture and complete mandibular denture provided on September 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foresophagogastroduodenoscopy, flexible, transoral; biopsy; single or multiple (43239) provided August 20, 2020.You asked the Plan to waive the copayment forthe esophagogastroduodenoscopy. You say that you have had the procedure done for a few years. You have never had to pay before. You are living on a limited amount of money each month and can't pay bills like this.The Plan denied your request. The Plan says the claim was processed and the correct copayment was applied per the Evidence of Coverage.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 $225 for each outpatient hospital facility visit for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay $225 for each outpatient hospital facility visit for the esophagogastroduodenoscopy. the esophagogastroduodenoscopy falls within the Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. benefit category. This means that you have been asked to pay the correct amount based on your contract withthe 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 foresophagogastroduodenoscopy, flexible, transoral; biopsy; single or multiple (43239) provided August 20, 2020.
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 you need rehab.The Plan denied your request. The Plan says the services are not medically necessary.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-approveIRF care. Our reviewer says that the requested IRF care is not medically necessary. Our physician reviewer found the submitted records show that you were admitted to the hospital for colitis and a urinary tract infection. Your medical conditions are stable. You have no medical needs requiring an IRF admission. You have no complex nursing or rehabilitation needs. While you need physical and occupational therapy, you d not require an intensive therapy program 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: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveTecentriq 840mg/14ml vial for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is evidence of enrollment in a clinical trial.The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in Original Medicare and the plan cost-sharing for the same services.In this case, you asked the Plan to pre-approve the drug as part of a clinical trial. The Plan does not cover routinecosts associated with qualifying clinical trials.Therefore, we decided that the Plandoes not haveto pre-approveTecentriq 840mg/14ml vial for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestyle Libre continuous glucose monitoring system and supplies.
You asked the Plan to pre-approve the services. You say that this is medically necessary to help monitor your levels better. The Plan denied your request. The Plan says the enrollee does not meet the coverage criteria. 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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has asyptomatic hypoglycemia; however, she does not take insulin readings multiple times per day, and does not adjust insulin based on the readings. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestyle Libre continuous glucose monitoring system and supplies.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome infusion services (S9328) provided April 8, 2020.You asked the Plan to pay forthe home infusion services. You say that the services were medically necessary.The Plan denied your request. The Plan says this service is not eligible for Medicare payment.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code S9328 is not supported in the medical record. Specifically, per the National Physician Fee Schedule, code S9328 is listed with a status "I". This means that this CPT code is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met.Therefore, we decided that the Plan does not have to pay forhome infusion services (S9328) provided April 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services (99223) provided November 24, 2019.You asked the Plan to pay forthe physician services. You say that the services were medically necessary.The Plan denied your request. The Plan says the claim has already been paid.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 99223 is not supported in the medical record. Specifically, the claim at issue is a duplicate. This service has already been paid for the date of service at issue. Based on this information, we decided that Medicare rules for coverage of the physician services have not been met.Therefore, we decided that the Plan does not have to pay forphysician services (99223) provided November 24, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for x-ray exam of the wrist (73110) provided
on November 16, 2020.

You asked the Plan to adjust the copayment for the wrist x-ray. You say that you should only be expected to
pay the $10 copayment for an outpatient x-ray service. The Plan denied your request. The Plan says your copay
was 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 $100 for
outpatient diagnostic x-ray service provided by a specialist.

You have been asked to pay $76 for a wrist x-ray. Per the Plan's 2020 EOC, Medicare-covered outpatient x-ray
services are subject to a copay between $10 and $100. A $10 copay applies when the exam is provided at a
free-standing radiology clinic or a doctor's office, and up to a $100 copay applies for services provided by a
specialist at an outpatient hospital setting. The provider in question is an orthopedic specialist practicing at an
outpatient hospital center. 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 adjust the copayment for x-ray exam of the wrist
(73110) provided on November 16, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvethe Freestyle Libre continous glucose monitor for the enrollee.You asked the Planto pre-approvethe monitor. You say that this is medically necessary.The Plandenied your request. The Plansaysthis 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 the monitor. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found theenrollee's physician writes that the enrollee has used twice daily insulin for many years with good success. The guidelines require insulin use 3 times or more a day.  The documentation does not support that the enrollee requires frequent insulin adjustment on the basis of testing results.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 monitor have not been met.Therefore, we decided that the Plandoes not haveto pre-approvethe Freestyle Libre continous glucose monitor for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance response and treatment, no transport (A0998RR) provided on June 10, 2020.You asked the Plan to pay forthe ambulance response and treatment, no transport. You say that you were not aware that ambulance response without transport was not a covered benefit.The Plan denied your request. The Plan says if no transport occurs, the ambulance service is not covered by Medicare.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 10, 2020. 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 response and treatment, no transport (A0998RR) provided onJune 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe continuous positive airway pressure (CPAP) machine, battery kit, DC converter, and disinfectant spray purchased on July 28, 2020.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that reimbursement for oxygen equipment is limited to 36 monthly rental payments. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  We looked at the file and Medicare rules. The file shows that you purchased a CPAP machine on July 28, 2020. Medicare does not cover direct purchase of this equipment, it must be rented. The battery kit, DC converter, and disinfectant spray are not covered because they do not serve a purpose that is primarily medical in nature. Therefore, we decided that the Plan does not have to pay forthe continuous positive airway pressure (CPAP) machine, battery kit, DC converter, and disinfectant spray purchased on July 28, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided on October 1, 2020 by an out of network (OON) provider.You asked the Plan to pay forphysician services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says prior authorization was not 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 forphysician services provided on October 1, 2020 by an out of network (OON) provider.