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

We decided that the Plan does not have to pre-approvethe medical services to be provided to the enrollee by an out of network (OON) provider.You asked the Plan to pre-approvethe OON services. You say that the enrollee has been seeing the provider for his diabetic retinopathy.The Plan denied your request. The Plan says the enrollee's needs can be met within the plan 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these OON services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided to the enrollee by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit on November 6, 2019.You asked the Plan to waive the copayment fora specialist visit. You say that you saw a physician assistant and not the doctor and disagree with the charges.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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $30 copayment for visits provided in a specialist's office. You have been asked to pay a $30 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have beenasked 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 specialist visit on November 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forlab work provided on December 27, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that these services were medically necessary.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also 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. Wefound no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay forlab work provided on December 27, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for CPT codes 97605 and 27616 provided on October 7, 2019.
You asked the Plan to pay for CPT codes 97605 and 27616. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered as billed.
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 case file does not contain evidence that CPT code 97605 cannot be paid as it is billed, according to Medicare rules. The National Correct Coding Initiative Policy Manual does not contain an NCCI edit stating CPT code 97605 cannot be billed with the CPT code for the surgical procedure also performed on the same date. Furthermore, the case file does not contain evidence that CPT code 27616 cannot be paid as it is billed, according to Medicare rules. The Plan has not provided any documentation showing that the benefit for CPT code 27616 was included in the payment/allowance for another service/procedure that has already been adjudicated. There are no other claims provided by the Plan for review. Therefore, we decided that the Plan has to pay for CPT codes 97605 and 27616 provided on October 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for dialysis visits provided from June 3, 2019 to September 30, 2019.
You asked the Plan to waive the coinsurance for the dialysis visits. You say that this is thousands of dollars' worth of treatment that should be covered. 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 20% coinsurance for Medicare-covered renal dialysis. You have been asked to pay a total of $2,845.92 for the dialysis visits. The dialysis visits fall within the "Services to treat kidney diseases" 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 dialysis visits provided from June 3, 2019 to September 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a CPAP battery backup.
You asked the Plan to pre-approve a CPAP battery backup. You say that there is multiple power service failures so you need a CPAP battery backup. The Plan denied your request. The Plan says the supplier must ensure the enrollee's medical needs for the equipment use will be met on a continuous and ongoing basis and have a plan in place to deal with any equipment failure/interruptions that may be life-threatening.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. Medicare will not pay separately or make any additional payment for backup equipment. Therefore, we decided that the Plan does not have to pre-approve a CPAP battery backup.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ER visits provided on October 15, 2019 and October 19, 2019.You asked the Plan to waive the copayments for ER visits. You say that you disagree with the denied charges.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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. You had ER visits on October 15, 2019 and October 19, 2019. Therefore, you are responsible to pay a $90 copayment per each visit. The total amount you owe is: $180. You have been asked to pay the total copayment amount of $180 for ER visits. ER visits fall within the emergency care benefit category.This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayments for ER visits provided on October 15, 2019 and October 19, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea physical therapy (PT) re-evaluation.You asked the Plan to pre-approvethese services. You say that therapy was working for you.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.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 skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the submitted records show that you had prior therapy visits and reveal evidence of independence with a home exercise program. Your condition is described as chronic with a history of nerve damage. Your condition can be managed with an independent home program. The unique skills of a professional therapist are not required to safely and effectively provide treatment. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.We lookedat 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-approvea physical therapy (PT) re-evaluation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox for the enrollee.You asked the Plan to pre-approveBotox. You say that the enrollee has been getting Botox injections with excellent response.The Plan denied your request. The Plan says Botox is only covered under the medical benefit if it is being supplied directly from the doctor's office.The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.In this case, the requested medication will be dispensed by a pharmacy and will bebrought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approveBotox for the enrollee.Benefits for Botoxmay be available under Medicare Part D.Contactthe 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 insertion of an IUD (58300 and J7298) provided on October 21, 2019.You asked the Plan to pay for the IUD. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says IUDs are not a covered benefit by Medicare and are excluded from coverage.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 the IUD is not supported in the record. Specifically, per Medicare, IUDs are noncovered. Based on this information, we decided that Medicare rules for coverage of the IUD have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of an IUD (58300 and J7298) provided on October 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.You asked the Plan to pre-approve the debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments. The Plan denied your request. The Plan says you do not meet the criteria established to receive the debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments for 2020.The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning.In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and the Plan's rules. The file shows that your medical conditions are not eligible medical conditions under the Plan's debit card allowance benefit. Therefore, we decided that the Plan does not have to pre-approve a debit card for an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diagnostic injection services rendered on September 19, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code A9588 is not supported.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 A9588 is fluciclovine f-18, diagnostic, 1 millicurie.We find that CPT code A9588 is not supported in the medical record. Specifically, there is no documentation of the dosage of drug administered. 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 pay forthe diagnostic injection services rendered on September 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PathemaGX comprehensive next generation sequencing (NGS) BRCA panel.
You asked the Plan to pre-approve the NGS BRCA panel. You say that the enrollee has metastatic breast cancer and the records provided support the need for the panel being requested. The Plan denied your request. The Plan says the enrollee does not meet the Medicare rules for coverage because no information was provided to show how the requested testing will meet the enrollee's medical needs. The Plan says that the requested testing is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that BRCA testing is covered for certain indications. 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 NGS BRCA panel. Our reviewer says that the criteria for coverage of the requested panel have not been met. Our physician reviewer found the enrollee was diagnosed at age 77. The documentation does not support that the enrollee has at least 1 close blood relative with breast cancer diagnosed at 50 years of age or less; or at least 1 close blood relative with ovarian cancer; or at least 1 close blood relative with pancreatic cancer; or at least 1 close blood relative with prostate cancer (Gleason score greater than or equal to 7 or metastatic); or at least 1 close male blood relative with breast cancer; or at least 2 additional diagnoses of breast cancer in patient and/or in close blood relative(s) at any age. The documentation does not support that the enrollee is of ethnicity associated with higher pathogenic mutation frequency (e.g. Ashkenazi Jewish). 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 NGS BRCA panel have not been met. Therefore, we decided that the Plan does not have to pre-approve PathemaGX comprehensive next generation sequencing (NGS) BRCA panel.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on December 20, 2019 by an out
of network (OON) provider.
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The
Plan says that there is no network deficiency for these services and alternate network providers were found.
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 specialist services provided on December 20, 2019
by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 24, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no network deficiency for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 to the enrollee by an out-of-network provider on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the oral appliance to be provided by an out of network provider.
You asked the Plan to pre-approve the oral appliance. You say that the Plan does not have a provider in the enrollee's area. The Plan denied your request. The Plan says the necessary services may be obtained in-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 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/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the oral appliance to be provided by an out of network provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).You asked the Plan to pre-approve Prolia. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not met the step therapy requirements.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 Prolia. Our reviewer says that the criteria for coverage of Prolia have not been met. Our physician reviewer found the submitted documentation does not show that the enrollee has a history of osteoporosis-related fracture or has tried and failed zoledronic acid. The documentation also does not support that zoledronic acid would likely be less effective or have adverse effects for the enrollee in this caseWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane (J7318).
You asked the Plan to pre-approve Durolane. You say that Durolane is a better medication. The Plan denied your request. The Plan says step therapy requirements have not been met.
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 Durolane. Our reviewer says that the criteria for coverage of Durolane have not been met. Our physician reviewer found the Plan requires a trial of Monovisc and Orthovisc before they will approve the requested drug. The documentation does not support that you have tried Monovisc and Orthovisc or that these drugs would likely be less effective or would likely have adverse effects 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane (J7318).