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

We decided that the Plan does not have to pay for the enteral nutrition supplies provided from June 1, 2020 to December 31, 2020.

You asked the Plan to pay for the enteral nutrition supplies. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services were billed incorrectly.

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 codes E0776, B9002, B4150, B4035 are not supported in the medical record. Specifically, the documentation shows that the enrollee was in a skilled nursing facility for these dates of service. If a skilled nursing facility bills the durable medical equipment, it must obtain a supplier number from the National Supplier Clearinghouse and must use the ASC X12 837 professional claim format, or if permissible Form CMS-1500. This means that an invalid bill for facility was submitted. Based on this information, we decided that Medicare rules for coverage of the enteral nutrition supplies have not been met. Therefore, we decided that the Plan does not have to pay for the enteral nutrition supplies provided from June 1, 2020 to December 31, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve routine transportation trips.

You asked the Plan to pre-approve the routine transportation trips. You say that you are a dialysis patient and have it three times a week. You say that you cannot afford to pay for transportation on your own. You say that you are disabled and that the Plan is playing with your life. You say that no one told you that you would only have 40 transportation trips. The Plan denied your request. The Plan says the enrollee's benefit plan does not cover more than 40 one-way trips per plan year, no matter what reason they are being asked for.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 40 one-way routine transportation trips per year.

We looked at your request, the records in the case file, and the rules. The records show that you have received coverage for 40 one-way routine transportation trips in the 2021 calendar year. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on October 1, 2019 by an out-of-network (OON) provider.

You asked the Plan to pay for vision services. You say that you have supplemental insurance, and this should be coverage. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that prior authorization was not obtained for these services. The Plan says that there are in-network providers available 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 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 vision services provided on October 1, 2019 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for ultrasounds provided on October 19, 2020.

You asked the Plan to waive the copayments for ultrasounds. You say that it should only be considered one ultrasound with one copayment. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $110 copayment for each ultrasound. 

The record shows that the enrollee received two ultrasounds on October 19, 2020. Therefore, they are responsible to pay a $110 copayment per each ultrasound. The total amount they owe is $220. 

The enrollee has been asked to pay the total copayment amount of $220 for ultrasounds. Ultrasounds fall within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 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 copayments for ultrasounds provided on October 19, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Livalo.

You asked the Plan to pre-approve Livalo. You say that the enrollee is on Fenofibrate already and has had side effects from all other statins. You also say that Ezetimibe was not effective. The Plan denied your request. The Plan says Livalo does not fall under Part B coverage.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Livalo.

Benefits for Livalo 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost for the eye exam, ophthalmic ultrasound and refraction provided on April 14, 2021.

You asked the Plan to waive the cost for the eye exam, ophthalmic ultrasound and refraction. You say that you were not aware you would be charged $85 for a refraction and were not informed it wasn't covered by Medicare. The Plan denied your request. The Plan says the copayment for the eye exam and ultrasound applied correctly and the refraction is not a covered supplemental benefit from a non-network provider.

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 copayment per visit to an ophthalmologist or optometrist for Medicare-covered vision care and a $10 copayment for most x-rays and ultrasounds except as specified below. The refraction is not a Medicare covered benefit or a covered supplemental vision benefit.

You have been asked to pay a $20 copayment for the eye exam, a $10 copayment for the ophthalmic ultrasound and $85 for the non-covered refraction. The eye exam falls within the "Vision care" benefit category. The ophthalmic ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 for the eye exam, ophthalmic ultrasound and refraction provided on April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553).

You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554, K0553).
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to waive the deductible for outpatient mental health care provided from March 31, 2021, to April 21, 2021.

You asked the Plan to waive the deductible for outpatient mental health care. You say that you would not have brought the enrollee to this provider if you knew that they did not accept Medicaid. The Plan denied your request. The Plan says that the claims were processed correctly and the enrollee is 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). The enrollee's contract with the Plan says that enrollees must pay $0 for each individual visit for outpatient mental health care. 

The Plan says the enrollee must pay a deductible for outpatient mental health care. Based on the plan contract, however, the enrollee cannot be asked to pay more than $0 for each individual visit for outpatient mental health care. Therefore, we decided that the Plan has to waive the deductible for outpatient mental health care provided from March 31, 2021, to April 21, 2021.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) provided on January 6, 2021.

You asked the Plan to pay for the localized delivery of antimicrobial agents. The Plan denied your request. The Plan says this procedure is not a benefit under the dental 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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) provided on January 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on August 20, 2020.

You asked the Plan to waive the copayment for an MRI. You say that you should not owe anything for the services. 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 $40 copayment for advanced imaging provided by a specialist. 

You have been asked to pay a $40 copayment for an MRI. An MRI falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an MRI provided on August 20, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on March 31, 2021.

You asked the Plan to pay for the self-administrated drugs. You say that you went to the hospital by ambulance due to a blood clot. You say that you did not have transportation home until the next day. You say that you feel that it is the Plan's responsibility to pick up any charges accumulated from your overnight stay. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on March 31, 2021.

Benefits for the self-administrated drugs 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 30 additional routine transportation trips.

You asked the Plan to pre-approve the 30 additional routine transportation trips. You say that you have appointments for dialysis and other important treatment. The Plan denied your request. The Plan says the enrollee has met the plan limits, which were set in the subscriber agreement.

Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 24 one-way routine transportation trips per calendar year. 

We looked at your request, the records in the case file, and the rules. The number of routine transportation trips being requested would exceed the Plan maximum benefit allowance for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve 30 additional routine transportation trips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the visual field exam provided on May 25, 2021.

You asked the Plan to waive the copayment for the visual field exam. You say that that the appointment was not necessary. The Plan denied your request. The Plan says you have been asked to pay 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 $50 copayment for provider and professional services at an in-network specialist's office. 

You have been asked to pay a $50 copayment for the visual field exam. The visual field exam falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows you were charged for a visual field exam.

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 visual field exam provided on May 25, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a specialist visit and ultrasounds provided on December 3, 2020.

You asked the Plan to waive the copayments for a specialist visit and ultrasounds. You say that you already paid the copayments. 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 $45 copayment for specialist services. Your contract with the Plan also clearly says that you must pay a $150 copayment for radiological diagnostic radiology. 

You received a specialist visit on December 3, 2020. Therefore, you are responsible to pay the $45 copayment. 

You received an ultrasound on December 3, 2020. Therefore, you are responsible to pay the allowed amount of $139.56, which is less than the $150 copayment. You received an ultrasound on December 3, 2020. Therefore, you are responsible to pay the $150 copayment. 

The total amount you owe is: $334.56. 

You have been asked to pay the total amount of $334.56 for a specialist visit and ultrasounds. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. Ultrasounds fall within the outpatient diagnostic tests and therapeutic services and supplies 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 a specialist visit and ultrasounds provided on December 3, 2020.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Keytruda, Abraxane (nab-paclitaxel), carboplatin, ondansetron, and dexamethasone.

You asked the Plan to pre-approve the requested drug regimen. You say that the requested regimen is medically necessary. The Plan denied your request. The Plan says the step therapy criteria for Abraxane has not been met. The Plan says that the enrollee has not had a serious reaction to either solvent Taxol or docetaxel. The Plan also says that the requested regimen was denied correctly.

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 Abraxane. Our reviewer says that the request for Abraxane is not medically necessary. Our physician reviewer found the Plan requires a trial of drug Taxol or Docetaxel before they will approve Abraxane. In this case, the reviewer found that the enrollee has not tried and failed at least one of the required drugs. There is no documentation provided indicating that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the step therapy requirements have not been met. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Abraxane have not been met. Specifically, the file does not show that the enrollee has tried and failed at least one of the preferred drugs. Since one drug is denied, the whole course is denied. Therefore, we decided that the Plan does not have to pre-approve Keytruda, Abraxane (nab-paclitaxel), carboplatin, ondansetron, and dexamethasone.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endodontic therapy services represented by code D3320.

You asked the Plan to pre-approve the endodontic therapy services. You say that you dentist advised that you need a root canal. The Plan denied your request. The Plan says the requested service is not a covered benefit.

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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve endodontic therapy services represented by code D3320.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve repeat RFA of your facet joints (CPT code 64635 and 64636).
You asked the Plan to pre-approve the services. You say that you have severe pain, cannot stand straight and have difficulty walking. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Your records show that there has been an extended time of more than two (2) years since your last RFA and/or there is a question as to the source of the recurrent pain then diagnostic procedure must be repeated. Therefore, we decided that the Plan does not have to pre-approve repeat RFA of your facet joints (CPT code 64635 and 64636).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.

You asked the Plan to pre-approve a Group 2 power wheelchair and accessories. You say that you need a Group 2 power wheelchair and accessories. The Plan denied your request. The Plan says power wheelchairs are not covered as a separate DME payment when an enrollee lives in a facility that is licensed as a skilled nursing facility.

The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate and needed for use inside the home. Medicare does not consider a SNF to be a home. 

Part B does not pay for DME provided during a nursing home stay unless the nursing home qualifies as a beneficiary's home. A nursing home qualifies as a beneficiary's home only if it does not provide primarily skilled care or rehabilitation. Records show that a Group 2 power wheelchair and accessories is being requested for use in a SNF. Therefore, we decided that the Plan does not have to pre-approve a Group 2 power wheelchair and accessories.