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

We decided that the Plan does not have to waive the coinsurance for chemotherapy provided on July 29, 2019.
You asked the Plan to waive the coinsurance for chemotherapy. You say that you didn't choose the out-of-network doctors. You say that this should be processed in-network. The Plan denied your request. The Plan says the coinsurance 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). The enrollee's contract with the Plan clearly says that enrollees must pay 20% coinsurance for chemotherapy drugs from an in-network provider. The enrollee has been asked to pay $42.94, which is 20% of the allowed amount for chemotherapy. The allowed amount is $214.68 (20% x $214.68 = $42.94). Chemotherapy falls within the "Medicare Part B prescription drugs" benefit category. The records show that the claim was processed at the in-network rate. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for chemotherapy provided on July 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that your provider performed interpretation, and the referring provider was responsible for obtaining authorization. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and 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 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 March 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 for the tetanus, diphtheria, and pertussis (TDaP) vaccine rendered to you on September 9, 2019.
You asked the Plan to pay for these services. You say that you do not submit things to X. The Plan denied your request. The Plan says the vaccine is not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to these services. Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria, and pertussis (TDaP) vaccine rendered to you on September 9, 2019.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 28, 2019 by an out of network (OON) provider.You asked the Plan to pay for optometry services. You say that the enrollee resides in a nursing facility which asked this provider to examine the enrollee.The Plan denied your request. The Plan says the denial of payment for these services is correct, because thisprovider is out-of-network with the Plan and the referring nursing home is also out-of-network with the Plan.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 forthemedical services provided on August 28, 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 an expandable controller, harness, and electrical connection for the enrollee.
You asked the Plan to pre-approve the accessories. You say that this is medically necessary. The Plan denied your request. The Plan says it is not medically necessary to control the three approved power options through the joystick (drive interface).
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 accessories. Our reviewer says that the requested accessories are not considered medically reasonable and necessary in this case. Our physician reviewer found these are convenience items and will not serve to substantially improve the functioning of the member's PMD, or enhance MRADL performance. As such, they are not medically 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 the accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller, harness, and electrical connection for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an acrylic socket for your lower limb prosthesis.
You asked the Plan to pre-approve the requested socket. The Plan denied your request. The Plan says an acrylic socket is not needed for a preparatory prosthesis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. An acrylic socket (CPT Code L5629) was requested. We looked at the file, and Medicare rules. The records show that a preparatory prosthesis (L5540) was already approved by the plan. When this type of prosthesis is provided, the acrylic socket is not considered reasonable and necessary. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve an acrylic socket for your lower limb prosthesis.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on August 26,
2019.
You asked the Plan to pay for the subsequent nursing facility care. You say that it is the responsibility of the
rehab facility to obtain the proper authorization from the enrollee's insurance. The Plan denied your request.
The Plan says non-emergent, 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 and the referring rehab facility are not network providers 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 subsequent nursing facility care
provided on August 26, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for AR gene full gene sequence testing provided on September 3, 2019.
You asked the Plan to pay for genetic test. You say that this testing is covered by Medicare and was ordered by the enrollee's treating physician to determine a more effective treatment for the enrollee's condition. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test does not meet coverage criteria.
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. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules. 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 specify whether the ordering physician is in-network or out-of-network with the Plan. Without this information, we cannot determine whether the lab order made by the physician constitutes plan-directed care which would justify coverage of this test. The Plan says that they have denied payment administratively but did not provide any specific rationale to support this denial, nor any applicable rules which would support non-coverage. The record does not show that the Plan provided prior notice that this test would not be covered. Therefore, the Plan has not shown that their decision to deny payment for this test is correct or justified by Medicare rules. Therefore, we decided that the Plan has to pay for AR gene full gene sequence testing provided on September 3, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemedial branch blocks (MBBs).You asked the Plan to pre-approvethese services. Yousay that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic low back pain. There is no recent documented physical exam findings that support the diagnosis of lumbar facet syndrome, such as loading tests or range of motion measurements. There is no recent imaging. The requested MBBs are therefore not reasonable or medically 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approvemedial branch blocks (MBBs).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued SNF services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says medical necessity cannot be established for continued SNF level of coverage
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 continued SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on October 8, 2019.
You asked the Plan to pay for the knee orthosis (L1851)and suspension sleeve (L2397). You say that the orthoses were medically necessary. The Plan denied your request. The Plan says rules for telehealth services were not met.
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 the knee orthosis and suspension sleeve provided on October 8, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pay foroffice visit services provided on December 11, 2018 and December 12, 2018.You asked the Planto pay forthe services. You say that the plan should reconsider coverage.The Plandenied your request. The Plansaysthatthe records show an approved authorization, however either the service performed, the servicing provider, or the number of visits billed do not match what was approved on the authorization.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 provide any information about the approved authorization. It cannot be determined if the services rendered match the amount of services approved on the authorization.Therefore, we decided that the Planhas to pay foroffice visit services provided on December 11, 2018 and December 12, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye refraction received on September 27, 2019.
You asked the Plan to pay for the eye refraction. You say that you feel you should not be liable for this amount. The Plan denied your request. The Plan says the services received are not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when received through a vision care provider. We looked at the file and the Plan's rules. Review of the file shows that the refraction received is not a covered benefit since it was performed for a medical reason of Primary Open-Angle Glaucoma, Bilateral, Mild Stage. Eye refractions are only covered by your plan if performed by a participating provider and performed as a routine screening. Based on this information, we decided that the Plan's rules for coverage of the eye refraction
have not been met. Therefore, we decided that the Plan does not have to pay for the eye refraction received on September 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFreestyle Libre 14 day Sensors.You asked the Plan to pre-approveFreestyle Libre 14 day Sensors. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.We looked at the file and Medicare rules. Medicare guidelines say that in order for a CGM to be covered, all of the above criteria must be met. The enrollee must have been using a BGM and performing frequent (four or more times a day) testing. In this case, the file shows that the enrollee only performs blood glucose testing two times per day. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre 14 day Sensors have not been met.Therefore, we decided that the Plan does not have to pre-approveFreestyle Libre 14 day Sensors.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forelbow surgery and therapy provided fromApril 4, 2019throughApril 5, 2019.You asked the Plan to waive the coinsurance forelbow surgery and therapy. You say that this was an inpatient stay. You say that this should be a $370 copayment.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each outpatient hospital and observation service. You have been asked to pay a total of $3,574.87 for elbow surgery and therapy. Elbow surgery and therapyfallwithin the "Outpatient hospital services" benefit category. The records show that this was an outpatient procedure. 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 forelbow surgery and therapy provided from April 4, 2019 through April 5, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires prolonged
hospitalization and close physician monitoring. The Plan denied your request. The Plan says there are not
complicated wounds or medications which cannot be given in the current location.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our physician
reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) having
suffered bilateral strokes with hemorrhagic conversion. The enrollee was intubated/ventilated and subsequently
received a tracheotomy. The enrollee remains on a ventilator. The enrollee's long-term prognosis and treatment
goals are unclear. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage
in transferring the enrollee to the LTACH.
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 LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Planhasto pre-approvecyberknife treatment.You asked the Planto pre-approvethe treatment. You say that this is medically necessary.The Plandenied your request. The Plansaysthatthis would be covered if the enrollee was in a clinical study, or other forms of first line therapy are not available.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the treatment. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found this treatment for prostate cancer should not be considered investigational, and it can be considered an accepted standard, and as such meets standard medically necessary criteria (as ASTRO and NCCN recognize this treatment as an alternative therapy).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 treatment have been met.Therefore, we decided that the Planhas to pre-approvecyberknife treatment.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the out-of-network services. You say that you usually get your sensors from the out-of-network provider. The Plan denied your request. The Plan says there are in-network providers within your service area that can provide the items.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items at issue in this appeal. We found no exception that would require the Plan to pre-approve these out-of-network services. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on September 20, 2019.You asked the Plan to pay for the laboratory 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 acovered benefit.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, the laboratory services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forthe laboratory services provided on September 20, 2019.