Persius/hicric huggingface dataset:
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on June 27, 2019.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you had no knowledge that you would have a copayment at all. You say you have never had to pay in the past for this injection. 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 Part B chemotherapy prescription drugs and non-chemotherapy prescription drugs. You have been asked to pay $224.28 which is 20% of the allowed amount for the Part B injection. The allowed amount is $1,121.40. ($1,121.40 x 20% = $224.28). The Part B injection falls within the "Medicare Part B prescription drugs" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B injection provided on June 27, 2019.
Our decision is only about the June 27, 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waivethe coinsurance for the pulmonary function test you received on June 13, 2019.You asked the Plan to waivethe coinsurance. You say that you paid the copayment for the visit.The Plan denied your request. The Plan says you are responsible for the cost share.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare-covered non-radiological diagnostic services. Review of the file shows that you had a pulmonary function test on June 13, 2019. The test was allowed at $128.20. You have been asked to pay a 20% coinsurance for the testing, totaling $25.64 ($128.20 x 20% = $25.64). The services fall within the outpatient diagnostic services 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 waivethe coinsurance for the pulmonary function test you received on June 13, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 4, 2019 by out of network 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 provider is out-of-network. The Plan says that the referring provider, is also out-of-network. The Plan says that prior authorization was not obtained 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 Planhas 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. There is an on-line Medicare site to verify eligibility. 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 September 4, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and two resin-based composites
provided on August 6, 2019.
You asked the Plan to pay for the periodic oral evaluation and resin-based composites. You say that your
primary care physician said that you do not need a referral for a dentist. You also say that you were told you
could go to a dentist of your choice. The Plan denied your request. The Plan says this provider is out-of-network
and you did not receive prior authorization for the services. The Plan also says that services provided
by an out-of-network or non-contracted provided are 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, the requested items or services are not
covered when they are received out-of-network. Therefore, we decided that the Plan does not have to pay for
the periodic oral evaluation and two resin-based composites provided on August 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 26, 2019.
You asked the Plan to pay for the physician's services. 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 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 physician's services provided on August 26, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHumira for "the beneficiary" .You asked the Plan to pre-approveHumira. You say that Humira offers the enrollee the best chance at a long-term remission.The Plan denied your request. The Plan says the enrollee's plan does not cover outpatient prescription 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-approveHumira for "the beneficiary". Benefits for Humiramaybe available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a calibrated segmented pneumatic compression device (PCD) coded as E0652.
You asked the Plan to pre-approve the E0652 PCD. You say that the E0651 PC is not clinically proven to be helpful for those with lymphedema that extends onto the trunk. The E0652 is needed to treat this as it is causing trouble breathing. The Plan denied your request. The Plan says since the enrollee has not done a full four weeks of use of E0651, the criteria are not met.
The Plan follows Medicare rules. Medicare rules say that E0652 PCDs are covered when there has been a failure of a four week trial with a lower level PCD. 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 E0652 PCD. Our reviewer says that the requested E0652 PCD is not considered medically reasonable and necessary. Our physician reviewer found this enrollee has lymphedema, which extends proximally into the abdomen per records. The records indicate this 80 year old enrollee has failed exercise and elevation for symptoms of chronic lymphedema. There is no documentation that a 4-week in-home standard pump trial was ever implemented. 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 E0652 PCD have not been met. Therefore, we decided that the Plan does not have to pre-approve a calibrated segmented pneumatic compression device (PCD) coded as E0652.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve methotrexate 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 self-administered drugs are not a covered benefit.
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 methotrexate for the enrollee.
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: Surgery
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveinsertion of a stabilizing and separating device into the lower spine for the enrollee.You asked the Planto pre-approvethe device. You say that this is medically necessary.The Plandenied your request. The Plansaysthere is a lack of evidence to support that this device is as safe and effective as the gold standard of decompression.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 carefullyreview the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental at this time. More research is needed to show efficacy. It is not the best treatment option. It is not needed 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 the device have not been met.Therefore, we decided that the Plandoes not haveto pre-approveinsertion of a stabilizing and separating device into the lower spine for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approveIRF care. You say that the enrollee would like to return to the previous level of independence.The Plan denied your request. The Plan says the enrollee does not need multiple intensive therapies requiring the constant supervision by a doctor and nurse who are specialized in rehabilitation to safely participate in therapy.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, skin and O2 care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not haveto pre-approvead mission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveinpatient mental health treatment for the enrollee.You asked the Planto pre-approvethe treatment. You say that this is medically necessary.The Plandenied your request. The Plansaysthis may be covered if active treatment is required.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto determine if the Plan was correct in denying the request to pre-approve the treatment. Our reviewer says that the requested treatment is not medically reasonable or necessary. Our physician reviewer found based upon a review of the records provided forthe admission of this enrollee, it does not meet the criteria for continued acute inpatient mental health treatment for the dates in question of January 14, 2020 forward as this enrollee was not shown to be a danger to herself or others. She was not showing any auditory or visual hallucinations and was cooperative/compliant with treatment.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 not been met.Therefore, we decided that the Plandoes not haveto pre-approveinpatient mental health treatment for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

To make our decision we read all the papers in the filevery carefully. We used the Medicare rules. We looked to see if the Plan correctly followed Medicare rules and regulations.Medicare rules say that the Plan must give the member a subscriber agreement. It is a contract between the Plan and the member. Itis usually called the "Evidence of Coverage" (EOC) or "Member Agreement." We read this contract carefully to see what the Plan is supposed to cover.Medicare rulesThe rules say that plans must pay for a medical service or item if regular Medicare wouldpay for it in this case. You can find this rule at 42 CFR 422.101.The rules say that the supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) must have an order from the treating physician before giving any DMEPOS item to an enrollee. The supplier must keep the order and proof of delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. You can find this rule in the Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1 and 5.8.If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules.  Explanation of decision.We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided by HNC Medical Supplies from August 11, 2019 to October 30, 2019.You asked the Plan to pay for test strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). 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 test strips, lancets, control solution, and batteries provided by HNC Medical Supplies from August 11, 2019 to October 30, 2019.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment forthe blood pressure monitoring. We decided that the Plan does not have to waive the copayments forthe office visits and echocardiography. You asked the Plan to waive the copayments forthe office visits and diagnostic tests. You say that you only saw the doctor twice. You say that you shouldn't have a copayment each time.The Plan says that the copayments applied correctly.We decided that the Planhas to waive the copaymentforthe blood pressure monitoring. 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 medical records show that the blood pressure monitoring was performed on July 19, 2019. Since the echocardiography and blood pressure monitoring were performed on the same date, only one copayment applies. Therefore, we decided that the Plan has to waivethe copaymentforthe blood pressure monitoring. 
We also decided that the Plandoes not have to waive the copayments forthe office visits and echocardiography.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 a specialty physician and a$50 copayment for other outpatient diagnostic tests performed by a specialty physician. You have been asked to pay a $50 copayment for the office visit on July 9, 2019 and a $50 copayment for the echocardiography on July 19,2019. You have also been asked to pay $22.11, which is less than the standard $50 copayment for the office visit provided on August 23, 2019. Therefore, we decided that the Plan does not have to waive the copayments forthe office visits and echocardiography.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthoses provided on March 18, 2019 by out of network provider.You asked the Plan to pay for bilateral knee braces (L1852). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says you did not have 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 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 orthoses provided on March 18, 2019 by out of network provider.
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 July 31, 2019 to October 19, 2019.

You asked the Plan to pay for the glucose monitor (E0607), 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 July 31, 2019 to October 19, 2019.
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 June 30, 2019 to September 18, 2019.
You asked the Plan to pay for the glucose monitor (E0607), 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 June 30, 2019 to September 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 28, 2019 by out of network provider.  You asked the Plan to pay for Guardant360 testing. You say that you would like these services authorized. The Plan denied your request. The Plan says no prior authorization was 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 says that an in-network provider has the expertise to manage the enrollee's condition. 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 July 28, 2019 by out of network provider.