Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health oncology supervision palliative services.

You asked the Plan to pre-approve home health oncology supervision palliative services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 home health oncology supervision palliative services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the documentation shows that the primary reason for home health care is weight loss, weakness, incontinence. The documentation does not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. Therefore, the enrollee does not meet criteria for the requested services.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health oncology supervision palliative services have not been met. Therefore, we decided that the Plan does not have to pre-approve home health oncology supervision palliative services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services provided on February 3, 2020, through February 27, 2020.

You asked the Plan to pay for the therapy services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the claim was not submitted with the required modifier to process and pay the claim.

The Plan must follow Medicare rules. Medicare rules say that the claim must include the GN, GO or GP modifier to distinguish the discipline of the plan of care under which the service is delivered.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapy services have not been met. Specifically, multiple codes on this claim were not submitted with the required modifier. Therefore, we decided that the Plan does not have to pay for the therapy services provided on February 3, 2020, through February 27, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an MRI provided on October 2, 2020.

You asked the Plan to waive the copayment for an MRI. You say that you 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 $75 copayment for advanced imaging services provided in a specialist's office or freestanding facility. 

You have been asked to pay a $75 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 October 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an injection of vedolizumab (a Medicare Part B drug) provided on September 16, 2020.

You asked the Plan to waive the coinsurance for Part B drug. You say that in prior years you paid less for this service. The Plan denied your request. The Plan says the coinsurance amount you are being charged is 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 20% coinsurance for in-network injection. The allowed amount of the claim is $6,198, resulting in a coinsurance obligation of $1,239.60. 

You have been asked to pay 20% coinsurance for Part B drug. Part B drug 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 an injection of vedolizumab (a Medicare Part B drug) provided on September 16, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance services provided on August 18, 2020.

You asked the Plan to waive the copayment for ambulance services. You say that you were given false information from a representative and for this reason the enrollee should not be responsible for the charges. 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 $195 copayment for ambulance services. 

The enrollee has been asked to pay a $195 copayment for ambulance services. Ambulance services fall within the ambulance services 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 copayment for ambulance services provided on August 18, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 10 home health physical therapy visits.

You asked the Plan to pre-approve 10 home health physical therapy visits. You say that you need therapy for your shoulder and knee. The Plan denied your request. The Plan says you do not need continued physical therapy services.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 10 home health physical therapy visits. Our reviewer says that the criteria for home health physical therapy visits have not been met. Our physician reviewer found the records do not show that skilled therapy services are required to effectively provide treatment, care, or services in order to improve your level of function, or to establish or perform a maintenance program to prevent deterioration. Your functional level does not require skilled therapy. You were instructed in a home exercise program. Additional skilled physical therapy is not medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 10 home health physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 10 home health physical therapy visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a CT scan provided by additional information on October 6, 2020.

You asked the Plan to waive the copayment for a CT scan. You say that you should not have to pay for the fact that the doctors don't communicate. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $100 copayment for outpatient diagnostic tests/in-network/CT scan. 

You have been asked to pay a $100 copayment for a CT scan. Since a CT scan was provided, the correct copayment has been applied. A CT scan falls within the outpatient diagnostic tests/in-network/CT scan 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 a CT scan provided by a participating provider on October 6, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided November 7, 2020.

You asked the Plan to pay for the ambulance services. You say that you were following the COVID executive order for treatment in place. The Plan denied your request. The Plan says these services are not a covered benefit.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 7, 2020. 

The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on November 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 15, 2020, by an OON
provider.

You asked the Plan to pay for the OON services. You say that you were not told the test was going to an outof-
network provider. The Plan denied your request. The Plan says you have no coverage for out-of-network
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.

Both the ordering provider and the rendering provider in this case are not a network providers with the Plan.
The Plan had network providers available who could have provided the lab services at issue. The Plan did not
pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON
services. Therefore, we decided that the Plan does not have to pay for the lab services provided on September
15, 2020, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a back brace (L0650) provided on September 18, 2020.

You asked the Plan to pay for a back brace. You say that this is supported in the records. The Plan denied your request. The Plan says there is not a valid proof of delivery for this item.

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 does not contain a valid proof of delivery for the supplies provided in this case. The submitted proof of delivery is not itemized to show the specific items delivered, and the itemized invoice does not contain the carrier's tracking number. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a back brace (L0650) provided on September 18, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on June 25, 2020.

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 physician's services. 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 June 25, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a second routine eye exam received on October 9, 2019.

You asked the Plan to pay for the exam. You say that this should be paid for. The Plan denied your request. The Plan says this is a duplicate billing.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers routine eye exams once per year.

We looked at the file and the Plan's rules. An eye exam was already received less than a year before the one at issue in this case. Based on this information, we decided that the Plan's rules for coverage of the exam have not been met. Therefore, we decided that the Plan does not have to pay for a second routine eye exam received on October 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation.

You asked the Plan to pay for the problem focused limited oral evaluation. You say that you thought this
service would be covered. The Plan denied your request. The Plan says this service is not listed as a covered
benefit. The Plan also says that you signed a treatment plan at the provider's office indicating that there was no
coverage under your dental benefit for the problem-focused limited oral evaluation and acknowledging that you
would be fully responsible for the charge for this service.

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
problem focused limited oral evaluation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.

You asked the Plan to pre-approve Botox. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.

The Plan follows Medicare rules. Medicare rules say that Botox is only 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 Botox. Our reviewer says that the documentation does not support that the requested Botox is medically reasonable or necessary. Our physician reviewer found the enrollee has diagnoses of gastroparesis and constipation. Coverage for endoscopy with Botox injection into the pylorus has been requested. The documentation does not support that the enrollee meets LCD criteria for Botox.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve medical services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services can be provided by a network provider.

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 medical services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tetracycline HCL.

You asked the Plan to pre-approve Tetracycline HCL. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the requested drug is not a covered benefit.

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 Tetracycline HCL.

Benefits for Tetracycline HCL 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for bone and/or joint imaging.

You asked the Plan to pay for the bone and/or joint imaging. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.

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 bone and/or joint imaging.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve apicoectomy services of an anterior tooth.

You asked the Plan to pre-approve apicoectomy services of an anterior tooth. You say that you would like the plan to reconsider their denial. 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 apicoectomy services of an anterior tooth.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient hospital care for the enrollee.

You asked the Plan to pre-approve inpatient hospital care. You say that these services are medically necessary.
The Plan denied your request. The Plan says that there is no documentation provided to support the expectation
the enrollee will require a greater than 2 midnight stay.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.

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 inpatient hospital care. Our reviewer
says that inpatient hospital care is not medically reasonable and necessary for the enrollee. The enrollee is
undergoing a planned right hip arthroplasty. The enrollee is medically stable and has been provided medical
clearance to undergo this elective procedure. The planned procedure is under CPT code 27130 and is not listed
on the CMS Inpatient Only List. The procedure is currently approved as an ambulatory procedure. The record
does not show that the patient's necessary hospital care (including earlier ED and/or observation care) would
span two midnights. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria
for inpatient hospital care.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient hospital care have not been met. Therefore, we decided that the Plan
does not have to pre-approve inpatient hospital care for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the limited oral evaluation (D0140) and the periapical-first radiographic image (D0220).

You asked the Plan to issue reimbursement for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under your dental policy.

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 services provided are not among those covered under this benefit. Therefore, we decided that the Plan does not have to issue reimbursement for the limited oral evaluation (D0140) and the periapical-first radiographic image (D0220).