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

We decided that the Plan does not have to pre-approve front wheel walker with seat attachment.
You asked the Plan to pre-approve the DME. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says you have previously received the same item on May 24, 2019.
The Plan must follow Medicare rules. Medicare rules say that the reasonable useful lifetime of durable medical equipment is no less than five years. Replacement equipment may be granted when irreparable wear or irreparable damage is demonstrated or there has been a change in the enrollee's medical condition. We looked at the file and Medicare rules. In this instance, the submitted documentation indicates that you have has received a walker on May 24, 2019. The walker is still within the 5-year RUL and the documentation submitted does not show that the walker is irreparably worn, irreparably damaged, or that you had a change in medical condition to warrant the walker. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Therefore, we decided that the Plan does not have to pre-approve front wheel walker with seat attachment.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein (36475).
You asked the Plan to pre-approve the endovenous ablation therapy of incompetent vein. You say that the service is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that Endovenous Radiofrequency and Laser Ablation Occlusion Therapy is covered when certain criteria is met. 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 endovenous ablation therapy of incompetent vein. Our reviewer says that the service is not medically necessary. Our physician reviewer found that although the enrollee has venous insufficiency, the enrollee has a clinical exclusion to the requested treatment which is the presence of clinically significant or symptomatic peripheral artery disease.
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 endovenous ablation therapy of incompetent vein. have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous ablation therapy of incompetent vein (36475).
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-approve IRF care. You say that this is medically necessary. The Plan denied your
request. The Plan says care can be received in another setting.
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, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of
therapy can allow for measurable gains 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 have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from September 4, 2019, to October 4, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilitiesrequire prior authorization as outlined in the enrollee's EOC.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 onlyin 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. ThePlan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider from September 4, 2019, to October 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on September 19, 2019.You asked the Plan to pay forthe drugtesting services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records stating exactly what tests are to be performed.The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing services provided to the enrollee on September 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 24, 2019
You asked the Plan to pay for ultrasound study. You say that you are only the reading radiologist, cannot refuse service, and are submitting medical records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring practitioner is also out-of-network with the Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 24, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on April 25, 2019.
You asked the Plan to pay for drug tests. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not include a valid physician order, lab requisition, or medical records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a physician order or clear intent to order the specific lab services billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met. Therefore, we decided that the Plan does not have to pay for drug testing provided on April 25, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zyvox Tab 600 mg.
You asked the Plan to pre-approve Zyvox Tab 600 mg. You say that the requested medication is necessary. The
Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a
separate pharmacy benefit, therefore self-administered drugs do not meet the criteria for coverage.
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 Zyvox Tab 600 mg.
Benefits for Zyvox Tab 600 mg 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued coverage of Non Invasive ventilator (E0466).
You asked the Plan to pre-approve continued coverage of Non Invasive ventilator. You say that you need the machine because you have pulmonary problems that affect your breathing and you are also in a wheelchair so when you move around your home it takes a lot out of you. The Plan denied your request. The Plan says the records do not support medical necessity.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 continued coverage of Non Invasive ventilator. Our reviewer says that home ventilator is considered not medically necessary for this enrollee. Our physician reviewer found this enrollee has a diagnosis of COPD with hypercapnic respiratory failure, but the medical records do not include testing documentation of either. There is no evidence for failure of BiPAP. Medicare does not cover a home ventilator when used as a BiPAP device. The patient may qualify for coverage of BiPAP, with appropriate documentation of hypercapnia and COPD. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued coverage of Non Invasive ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve continued coverage of Non Invasive ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on August 29, 2019.
You asked the Plan to pay for the services. You say that you did not know this provider was out-of-network. The Plan denied your request. The Plan says you plan does not included out-of-network benefits.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on August 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on July 29, 2019.You asked the Plan to waive the copayment for the x-ray. You say that you were informed you had no copayment. You say that you do not have the money to pay.The Plan denied your request. The Plan says the copayment 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 a $150 copayment when x-rays are performed in an outpatient hospital facility.You have been asked to pay a $150 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the x-ray was billed by the hospital. 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 forthe x-ray provided on July 29, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided by an in-network provider from August 22, 2019 through August 24, 2019.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you were in the emergency room from August 22, 2019 through August 23, 2019 and then inpatient from August 23, 2019 through August 24, 2019. You state that only one daily inpatient copayment should apply. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you went to the emergency room at 9:44 am on August 22, 2019. You were then admitted to the hospital from the emergency room at 1:07 pm on August 22, 2019. Therefore, August 22nd counts as inpatient day one (1). You remained inpatient on August 23, 2019, which counts as inpatient day two (2). You were discharged at 2:30 pm on August 24, 2019, which does not count as an inpatient day. You are asked to pay a $200 copayment per day from August 22, 2019 through August 23, 2019, days 1-2 of your inpatient hospital care. 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 inpatient hospital care provided by an in-network provider from August 22, 2019 through August 24, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on July 30, 2019.You asked the Plan to waive the copayment forthe ED visit. You say that you were informed they could not provide services.The Plan denied your request. The Plan says the copayment 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 a $90 copayment for Medicare covered emergency room visits.You have been asked to pay $80.19, which is less than the standard$90 copayment for the ED visit. The ED visit falls within the "Emergency care" benefit category.The records show that you were examined during the ED visit.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 forthe ED visit provided on July 30, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the office visit provided on September 19, 2019.You asked the Plan to waive the deductible forthe office visit. You say that you submitted your insurance card prior to your appointment to make sure you were covered. You say that you are not liable for the bill.The Plan denied your request. The Plan says the deductible applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that your deductible is $750 for out-of-network services. This is the amount you have to pay out-of-pocket before we will pay our share for your covered medical services. Until you have paid the deductible amount, you must pay the full cost for most of your covered services.The item or service you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $750 deductible applies to out-of-network services. This cost sharing is a contractual obligation that had not been met at the time the out-of-network office visit was received on September 19, 2019. Therefore, we decided that the Plan does not have to waive the deductible forthe office visit provided on September 19, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for office visit services provided on July 3, 2019.
You asked the Plan to pay for the services. You say that you were pre-approved by the case manager for this procedure. The Plan denied your request. The Plan says there was no referral for this.
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 rendering provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for office visit services provided on July 3, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting (76377)
provided on January 9, 2019.
You asked the Plan to pay for 3D rendering with interpretation and reporting. You say that this service is not
separately payable. The Plan denied your request. The Plan says this was medically necessary.
The Plan follows Medicare rules. Medicare rules say that CPT codes 76376 and 76377 may be considered
medically unnecessary and denied if equivalent information to that obtained from the test has already been
provided by another procedure.
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 pay for 3D rendering with interpretation and reporting. Our reviewer says that this was not medically necessary. Our physician reviewer found as the record shows that enrollee had undergone a detailed MRI study which was reviewed at a conference by MRI radiologists, the 3D rendering was determined 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 3D rendering with interpretation and reporting have not been met. Therefore, we decided that the Plan does not have to pay for 3D rendering with interpretation and reporting (76377) provided on January 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided by the doctor on October 2, 2019.
You asked the Plan to waive the copayment for a specialist visit. You say that this was a regular office visit and you should not be responsible for 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 $35 copayment a specialist office visit. The record shows that you had a specialist office visit on October 2, 2019. Therefore, you are responsible to pay a $35 copayment. You have been asked to pay a $35 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. This means that you have 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 specialist visit provided by the doctor on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided  by an out-of-network
provider on June 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services
rendered by non-participating providers in non-participating facilities require prior authorization as outlined in
the enrollee's EOC.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided by an out-of-network provider
on June 12, 2019.