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

We decided that the Plan does not have to pay forspecially stained specimen slides to identify organisms including interpretation and report (88312) provided on August 9, 2019 by an out of network provider. You asked the Plan to pay forspecially stained specimen slides to identify organisms including interpretation and report. You say that you are asking to reconsider your denial decision of CPT code 88312. You say you are the laboratory that received a nail specimen for testing. These stains were necessary because of the clinical concern of the possibility of a fungal infection.The Plan denied your request. The Plan says the services are not authorized because the lab is a non-network provider who does not work with the member's health plan, and the member was referred by the provider, who also does not work with the member's plan. The member's primary care physician did not refer for services. The health 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 beendocumented.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 forspecially stained specimen slides to identify organisms including interpretation and report (88312) provided on August 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital services, professional services, and sales tax provided from March 18, 2019 to April 3, 2019.

You asked the Plan to pay for out-of-country services. You say that you feel you are being treated unfairly and want to be reimbursed for these expenses. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the Plan has already paid the maximum $25,000 benefit for worldwide coverage and you are responsible for any charges beyond this amount.

The Plan must follow Medicare rules. Medicare rules say that services furnished outside of the United States and its territories are not covered by Medicare except in certain, specific circumstances. Medicare rules also say that Medicare does not make separate payment for sales taxes. The Plan offers a supplemental benefit for worldwide coverage that goes beyond Medicare's coverage. The Plan covers worldwide emergency care services up to $25,000 per year. Enrollees must pay all costs over $25,000 and any costs to return to the Plan's service area.

We looked at the file and Medicare rules. These services provided in Mexico, and the sales taxes charged, are not covered by Medicare. These services were covered by the Plan's supplemental worldwide coverage benefit, however the Plan has paid the $25,000 maximum benefit for worldwide coverage so you are responsible for any charges beyond this amount. Based on this information, we decided that the Plan's rules for coverage of out-of-country services have not been met. Therefore, we decided that the Plan does not have to pay for hospital services, professional services, and sales tax provided from March 18, 2019 to April 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.You asked the Plan to pre-approvethe compression stockings. You say that you need the requested compression stockingswith zippers. You say that you have severe arthritis in your wrists and hands. You say that you have poor hand dexterity and strength from rheumatoid arthritis and gout. You say that you rheumatologist can verify your condition. You say that you are unable to get the normal stockings on. You say that you are at high risk for blood clots with a-fib and varicose veins.The Plan denied your request. The Plan says the item being requested is not a covered benefit.The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the clinical documentation provided supports the need for LTACH care.The Plan denied your request. The Plan says the needed services can be provided in the acute care hospital or in a lower level of care once heparin is stopped.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 acute care hospital (ACH) for respiratory failure attributed to pneumonia and complicated by renal failure/fluid overload. You say that the enrollee was initially treated with BiPAP,was subsequently intubated/ventilated, and eventually received a tracheotomy. Our physician reviewer found that the enrollee remains on a ventilator, weaning from which appears to be limited due to ongoing fluid overload. Our physician reviewer found thatthere is no advantage in transferring the enrollee to the LTACH. Our physician reviewer found that the enrollee can remain at the current ACH until such time no acute services are required.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Buprenorphin tablets.You asked the Plan to pre-approveself-administered drugs. You say that you are appealing with records.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 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-approveBuprenorphin tablets.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an endoscopy (43235) provided on September 3, 2019.

You asked the Plan to waive the copayment for an endoscopy. You say that you should not have a copayment because this service was done at the same time as a screening colonoscopy. The Plan denied your request. The Plan says this service processed 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 $225 copayment for outpatient surgery at an in-network ambulatory surgical center. 

You have been asked to pay a $185.15 copayment for an endoscopy. An endoscopy falls within the outpatient surgery at an in-network ambulatory surgical center benefit category. This means that you have been asked to pay less than the required copayment 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 endoscopy (43235) provided on September 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea consultation to be providedby an out of network provider.You asked the Plan to pre-approvethe consultation. You say that you need to see a knee orthopedic surgeon.The Plan denied your request. The Plan says the services can be provided within the primary network.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-approvea consultation to be provided by an out of network provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided to the enrollee and billed under code S9328.You asked the Plan to pay forcode S9328. You say that this claim should be paid.The Plandenied your request. The Plan says this code has a status indicator of "I" meaning this code is not used for Medicare billing purposes.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, code S9328 is not appropriate for Medicare billing purposes. Therefore, we decided that the Plan does not have to pay forhome health services provided to the enrollee and billed under code S9328.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Norvasc tab 5mg for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is an oral medication.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 Plandoes not haveto pre-approveNorvasc tab 5mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services provided to the enrollee on August 1, 2019.You asked the Plan to pay forthis service.You say that this claim should be paid. The Plandenied your request. The Plan says the enrollee did not have prior authorization for out of network care. 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 servicesat 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 forphysician services provided to the enrollee on August 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 5mg Cyclobenzaprine tablets.You asked the Plan to pre-approvethe Cyclobenzaprine. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says your drug coverage is limited to Medicare Part B 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 PartB.Therefore, we decided that the Plan does not have to pre-approve5mg Cyclobenzaprine tablets.Benefits for the Cyclobenzaprinemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveCalquence Cap 100mg for the enrollee.You asked the Plan to pre-approvethe drug. You say that this is medically necessary.The Plan denied your request. The Plan says this is 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-approveCalquence Cap 100mg for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay forcounseling services provided to the enrollee from August 5, 2019 to August 26, 2019 by "the provider".You asked the Plan to pay forthis service. You say that these claims should be paid.The Plan denied your request. The Plan says the Medicare provider database contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation. This dataset is updated twice a month with the most current demographic information available at that time. A search of the NPI number indicates no provider found to be eligible to bill Medicare.The Plan states a review will be done of any previously paid claims paid in error and will be recouped. The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who is not eligible to bill Medicare. The services at issue in this appeal were provided in a non-urgent, non-emergent situation. This provider is not eligible to bill Medicare. Therefore, we decided that the Plan does not have to pay forcounseling services provided to the enrollee from August 5, 2019 to August 26, 2019 by "the provider".
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe wheelchair purchased on July 18, 2019.You asked the Plan to reimburse you forthewheelchair. You say that the enrollee needed a wheelchair right away so you bought one.The Plan denied your request. The Plan says you did not have prior authorization for the wheelchair.Medicare rules say that plans can require enrollees to get care from network providers. The Plan did not pre-approve the itemat issue. The Patient Order is dated after the purchase date. Criteria for a wheelchair have not been met. We found no exception that would require the Plan to reimburse you for thisitems.Therefore, we decided that the Plan does not have to reimburse you forthe wheelchair purchased on July18, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on July 5, 2019 out of network.You asked the Plan to pay for this service. You say that this claim should be paid.The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan mustpay 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 caseis 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 forphysician services provided to the enrollee on July 5, 2019 out of network.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHyalgan injection for the enrollee.You asked the Plan to pre-approvethe drug. You say that this is medically necessary.The Plan denied your request. The Plan says "the plan's" preferred viscosupplements are Orthovisc and Monovisc and don't require prior authorization.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 the drug. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found there is no evidence of a trial and failure of Orthovisc and Monovisc. The documentation does not support that Orthovisc and Monovisc 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 the drug have not been met.Therefore, we decided that the Plan does not have to pre-approveHyalgan injection for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99214) and the measurement of glucose in the blood using a reagent strip (82948) provided on August 16, 2019.You asked the Plan to pay foran office visit and the measurement of glucose in the blood using a reagent strip. You say that you are requesting a review of the services in the appeal due to medical necessity. You state the member did not advise the provider's office that she had a new insurance plan.The Plan denied your request. The Plan says the claim does not meet the urgent or emergent criteria based on the CPT codes and diagnosis codes submitted. The Plan says the member is enrolled in an HMO plan with no out of network benefits. The Plan further says that there is no documentation that this member was referred to this non-contracted provider by a contracted provider, as well as no indication any attempt was made to obtain prior authorization for these 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.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 foran office visit (99214) and the measurement of glucose in the blood usinga reagent strip (82948) provided on August 16, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that the enrollee is not safe to go home.The Plan denied your request. The Plan says that the enrollee does not require daily skilled nursing and/or daily skilled rehabilitation services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct indenying the request to pre-approve SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit for the evaluation and management of an established patient provided on September 18, 2019 by an out of network provider.You asked the Plan to pay fora domiciliary or rest home visit for the evaluation and management of an established patient. You say that you are appealing claim payment denial for services rendered to your member on date of service September 18, 2019.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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exceptionthat would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay fora domiciliary or rest home visit for the evaluation and management of an established patient provided on September 18, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional Wellness Allowance for the gym membership provided, for the 2018 and the 2019 benefit year.You asked the Plan to reimburse you forthe gym membership. The Plan denied your request. The Plan says you have already been reimbursed the maximum amount towards your 2018 and 2019 Wellness Allowance.The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers gym benefits up to a $150Wellness Allowanceeach calendar year.We looked at the file and the Plan's rules. The file shows thaton March 9, 2019, the Planreimbursed you a $150 Wellness Allowance forthe 2018 benefit year and on May 11, 2019, the Plan reimbursed you a $150 Wellness Allowance for the 2019 benefit year. Therefore, we decided that the Plan does not have to reimburse you an additional Wellness Allowance forthe gym membership provided for the 2018 and the 2019 benefit year.