Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe eye exam and ultrasound provided on October 15, 2019.You asked the Plan to waive the copayments forthe eye exam and ultrasound. You say that you've never had to pay for these services before.The Plan denied your request. The Plan says that the copayment applied was correct.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 for visits to an ophthalmologist or optometrist for Medicare-covered vision care and a $10 copayment for an ultrasound. You have been asked to pay a $20 copayment and a $10 copayment for the eye exam and ultrasound. The eye exam falls within the visits to an ophthalmologist or optometrist for Medicare-covered vision care and theultrasoundfalls within theultrasound 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 forthe eye exam and ultrasound provided on October 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH)
for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says the enrollee is receiving appropriate inpatient acute care, and does not
require transfer to LTACH.
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 reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee is currently undergoing treatment at an ACH for MRSA pneumonia. The
enrollee is not currently intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of
care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current
ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower
level of care for any ongoing long term care needs.
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 admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foroffice visit services provided to the enrollee on August 7, 2019.You asked the Plan to pay forthe services. You say that the services were coded correctly, and the services were medically necessary.The Plan denied your request. The Plan says the billed primary diagnosis code is not appropriate.The Plan must follow Medicare rules.Medicare rules say that a sequela code cannot be billed as the first-listed primary diagnosis.The case file shows that ICD-10 diagnosis code T79.6XXS was billed as the primary diagnosis code. This is a sequela code, and cannot be billed as the primary code. 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 pay foroffice visit services provided to the enrollee on August 7, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services for a consultation.
You asked the Plan to pre-approve the physician's services. You say that you have been in pain after trying
epidural and radiofrequency ablation treatments. You say that these interventions have not worked and you would like a
consultation.
The Plan denied your request. The Plan says care you receive from an out-of-network provider will not be covered.
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 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. We found no exception that would require the
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve
physician's services for a consultation to be provided by the requested provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 20, 2019 by out of network provider, "the provider". You asked the Plan to pay foroutpatient lab work. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that there are multiple in-network providers within 30 miles of the member's residence that could render these services.Medicare rules say that plans can require enrollees toget 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 forthe medical services provided on August 20, 2019 by out of network provider, "the provider".
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe duplex scan provided on August 21, 2019.You asked the Plan to waive the coinsurance forthe duplex scan. You say that you were not informed there would be an extra charge. You say that you shouldn't be responsible for the coinsurance.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 Medicare-covered radiological diagnostic service.You have been asked to pay $39.34, which is 20% of the allowed amountfor the duplex scan. The allowed amount is $196.70 (20% x $196.70 = $39.34). The duplex scanfalls 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 coinsurance forthe duplex scan provided on August 21, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approveArtacent wound, per square centimeter for the enrollee.You asked the Plan to pre-approvethe services. You say that this is medically necessary.The Plan denied your request. The Plan says that this product is not covered, and will be processed as "not separately payable."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 services. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the use of Artacent Wound for the non-healing ulcer on right foot in this case is medically reasonable and necessary, because the first line treatment approaches have failed.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 been met.Therefore, we decided that the Plan has to pre-approveArtacent wound, per square centimeter for the enrollee.If the Plan does not agreewith 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 8, 2019 to October 27, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from August 8, 2019 to October 27, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia provided on August 26, 2019.
You asked the Plan to pay for the anesthesia. You say that the member was not enrolled in hospice on this date of service. You say the member's enrollment termed on August 24, 2019. The Plan denied your request. The Plan says Original Medicare is responsible for payment of all Medicare-covered services related or unrelated to the member's terminal illness and Medicare is still responsible for payment until the start of the next month after revocation.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The member was under the Medicare hospice benefit for the dates of service at issue in this appeal. The record shows the patient was enrolled in hospice from August 22, 2019 to August 24, 2019. However, Medicare is still responsible for payment until the start of the next month after revocation. Therefore, we decided that the Plan does not have to pay for anesthesia provided by on August 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Glatiramer.
You asked the Plan to pre-approve self-administered drugs. You say that you have an approved authorization
for this drug. The Plan denied your request. The Plan says the denial of authorization for this drug is correct,
because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare
Part D prescription drug benefits. The Plan also says that the enrollee's Medicare Part D prescription drug
benefits may be administered by Silver Scripts.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Glatiramer.
Benefits for self-administered 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an EKG provided on August 16, 2019.
You asked the Plan to pay for the EKG. The Plan denied your request. The Plan says that the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for an EKG provided on August 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from October
15, 2019 through October 18, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you told the provider you did
not want a private room. You say that you have never had to pay this type of balance. The Plan denied your
request. The Plan says the claim reprocessed to only apply the standard inpatient copayment.
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 $275
copayment per day, days 1 to 5 at an in-network inpatient hospital.
You have been asked to pay a $825 copayment for the inpatient stay. ($275/day x 3 days = $825). The inpatient
stay falls within the "Inpatient hospital 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 copayment
for the inpatient stay provided from October 15, 2019 through October 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Diclofenac Sodium 1% Gel for the enrollee.
You asked the Plan to pre-approve the gel. You say that this is medically necessary. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.
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 Diclofenac Sodium 1% Gel for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve esophageal sphincter augmentation for the enrollee.
You asked the Plan to pre-approve these 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 procedure code 43284 is denied as not reasonable and necessary at this time. The services at issue are an esophageal sphincter augmentation described by procedure code 43284. These services are denied by Medicare as not reasonable and medically necessary. Therefore, we decided that the Plan does not have to pre-approve esophageal sphincter augmentation for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray provided on August 16, 2019.
You asked the Plan to pay for the panoramic x-ray. You say that this panoramic x-ray was medically necessary. You also say that this service was an emergency because you had an infection, swelling, and it was impacting your ability to live a normal life. The Plan denied your request. The Plan says this service is not a covered benefit under your 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 panoramic x-ray provided on August 16, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided from
April 25, 2019 to April 29, 2019.
You asked the Plan to waive the copayment for the emergency room. You say that you should not be
responsible for the copayments and you are on a fixed income. The Plan denied your request. The Plan says
you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90
copayment for an out-of-network emergency room.
You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls
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 copayment for the
emergency room visit provided from April 25, 2019 to April 29, 2019.
Your complaint about the hospital's error in sending you home too soon 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on February 6, 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 the orthosis is a duplicate to the knee orthosis the enrollee received in 2018.
The enrollee's knee orthosis, provided on September 25, 2018 from a different provider, is still within the 5-year RUL. The documentation submitted does not show that the orthosis is irreparably worn, irreparably damaged, or that the enrollee had a change in medical condition to warrant the knee orthosis at issue. Based on the records provided, there is no indication the orthoses provided met Medicare coverage criteria for replacement at the time of issue. Medicare coverage criteria for orthoses replacement were not met.. Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on February 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110), bitewing x-rays (D0274), comprehensive oral evaluation (D0150), the initial intraoral x-ray (D0220), and the additional intraoral x-ray (D0230) provided on September 12, 2019.
You asked the Plan to pay for the dental services. You say that your wife found the dentist on the Plan's website while searching for an in network dental provider. The Plan denied your request. The Plan says the dentist in this case is out of network with the Plan. The Plan also says that care rendered by a provider that is not part of the Plan's supplemental dental network is not covered.
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, dental services received out of network are not covered. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110), bitewing x-rays (D0274), comprehensive oral evaluation (D0150), the initial intraoral x-ray (D0220), and the additional intraoral x-ray (D0230) provided on September 12, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Hyalagen (J7321).
You asked the Plan to pre-approve Hyalagen. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee has not tried and failed Monovisc and Orthovisc as required by step therapy rules.
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 Hyalagen. Our reviewer says that criteria for coverage of Hyalagen 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 the enrollee has tried and failed Monovisc and Orthovisc or that Monovisc and Orthovisc would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Hyalagen have not been met. Therefore, we decided that the Plan does not have to pre-approve Hyalagen (J7321).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services rendered to the enrollee by "the provider" on July 4, 2019 to July 9, 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 the claims were not billed correctly.The Plan must follow Medicare rules. The rules say that a treatment authorization code is required for home health claims.We looked at the file and Medicare rules. The claims were not billed with the required treatment authorization code. 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 home health services rendered to the enrollee by "the provider" on July 4, 2019 to July 9, 2019.