Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on October 10, 2019 by an out of network (OON) provider.
You asked the Plan to pay for home health services. You say that the member was treated in a rest home. You say that the patient has no choice of provider. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the referring provider is also out-of-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 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 home health services provided on October 10, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cervical facet blocks (64490).
You asked the Plan to pre-approve the cervical facet blocks. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the records do not show that the member has tried and failed conservative therapy for at least 6 weeks.
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 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 cervical facet blocks. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member does not have a documented trial of physical therapy or other conservative therapy such as chiropractic or physical medicine methods.
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 cervical facet blocks have not been met. Therefore, we decided that the Plan does not have to pre-approve cervical facet blocks (64490).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 3, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without 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 for the medical services provided on September 3, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ophthalmology services providedon September 24, 2019.
You asked the Plan to waive the copayment for ophthalmology services. You say that you requested routine vision services and 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 $35 copayment for specialist services. The medical records show that you received ophthalmology services on September 24, 2019 due to blurred vision. Therefore, you are responsible to pay the $35 copayment. You have been asked to pay a $35 copayment for ophthalmology services. Ophthalmology services fall 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 ophthalmology services provided on September 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on May 14, 2019.
You asked the Plan to pay for the shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was medically necessary. The Plan denied your request. The Plan says the doctor notes from March 27, 2019 do not mention shoulder or arm pain.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not support medical necessity for the orthosis. Based on this information, we decided that Medicare rules for coverage of the shoulder-elbow-wrist-hand orthosis (L3960) have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on May 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 15 MCG.2 ML Brovana.
You asked the Plan to pre-approve the Brovana. You say that the Brovana is medically necessary for treatment of the member's condition. The Plan denied your request. The Plan says no documentation was submitted supporting the medical necessity of a step therapy exception.
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 Brovana. Our reviewer says that the member has not tried and failed a trial of Perforomist. Our physician reviewer found there was no rationale submitted for using Brovana instead of Perforomist.
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 Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve 15 MCG.2 ML Brovana.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an intravitreal injection and to waive the coinsurance for a Medicare Part B drug provided on October 17, 2019.
You asked the Plan to waive the copayment for an intravitreal injection and to waive the coinsurance for a Medicare Part B drug. You say that you cannot afford 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 $250 copayment for surgery services provided in an outpatient hospital facility. Your contract with the Plan also clearly says that you must pay 20% coinsurance for Medicare Part B prescription drugs. You received an intravitreal injection on October 17, 2019. An intravitreal injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment. You received a Medicare Part B drug on October 17, 2019. The allowed amount is $10.15 and 20% coinsurance for $2.03. The total amount you owe is: $252.03. You have been asked to pay the total amount of $252.03 for an intravitreal injection and a Medicare Part B drug. An intravitreal injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. A Medicare 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 copayment for an intravitreal injection and to waive the coinsurance for a Medicare Part B drug provided on October 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX Injections (J7321).
You asked the Plan to pre-approve Supartz FX. You say that the injections are medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 Supartz FX. Our reviewer says that the Supartz FX injections are not medically necessary. Our physician reviewer found documentation supports the enrollee has used non-steroidal anti-inflammatory medication, diclofenac gel, kenalog injections, and hyaluronic acid injections. Submitted documentation supports the enrollee had mild improvement following injections in June of 2019, but has since had increase in symptoms. The specific hyaluronic acid injection used at this time was not included in the documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Supartz FX have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX Injections (J7321).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an annual cochlear implant check-up.
You asked the Plan to pre-approve the annual cochlear implant check. You say that the location is closer to the enrollee's home. The Plan denied your request. The Plan says the enrollee must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve the requested annual cochlear implant check-up.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for home health services provided on January 15, 2018 through March 2, 2018.
You asked the Plan to pay for the home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that the claim was submitted with inappropriate home health data to process and pay.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that CPT code the home health services are supported in the record. Specifically, per Medicare, revenue code 0421 is an appropriate code for the physical therapy code, G0151. Additionally, the claim was submitted on type of bill 0327 which is appropriate for adjusted claims. Based on this information, we decided that Medicare rules for coverage of the home health services have been met. Therefore, we decided that the Plan has to pay for home health services provided on January 15, 2018 through March 2, 2018.
Appeal type: Outpatient Mental Health
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 from February 28, 2018, to October 26, 2018.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says a referral 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 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 from February 28, 2018, to October 26, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc (J7325).
You asked the Plan to pre-approve Synvisc. You say that the Synvisc is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says the documentation submitted does not support the medical necessity of a step therapy exception.
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 Synvisc. Our reviewer says that the record does not show that the member has tried and failed a trial of Orthovisc and Monovisc. Our physician reviewer found the provider does not indicate that the preferred drugs would likely be less effective, and/or would likely have adverse effects.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc (J7325).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an epidural injection provided on November 8, 2019.
You asked the Plan to waive the copayment for an epidural injection. You say that you had the procedure in the past were never charged a copayment. 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 150 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received an epidural injection on November 8, 2019. An epidural injection is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $150 copayment. You have been asked to pay a 150 copayment for an epidural injection. An epidural injection falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 epidural injection provided on November 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee from January 1, 2019, to July 31, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this provider is not Medicare-Certified.
The Plan must follow Medicare rules. Medicare rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program. We looked at the file and Medicare rules. The services in question were provided by a provider who is not enrollee in the Medicare program. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee from January 1, 2019, to July 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided on October 4, 2019.
You asked the Plan to pay for the outpatient hospital 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 service 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 outpatient hospital services provided on October 4, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the treatment of a femoral fracture provided on September 25, 2019.
You asked the Plan to pay for the surgical service. You say that the enrollee was not enrolled in hospice on the date of service. The Plan denied your request. The Plan says the enrollee's claim would be covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on September 23, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the treatment of a femoral fracture provided on September 25, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 3, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the cost-sharing is too high. The Plan denied your request. The Plan says that the claim 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 $150 copayment for each Medicare-covered one-way trip. You have been asked to pay a $150 copayment for the ambulance transport. The ambulance transport falls within the Medicare-covered one-way trip benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on August 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a PET CT (78816).
You asked the Plan to pre-approve the PET CT. You say that the PET CT is medically necessary. The Plan denied your request. The Plan says the enrollee does not have a confirmed diagnosis of cancer after multiple tests were performed.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 PET CT. Our reviewer says that the member does not meet Medicare coverage criteria for the PET scan. Our physician reviewer found cancer is not strongly suspected so the PET CT is not indicated per Medicare. 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 PET CT have not been met. Therefore, we decided that the Plan does not have to pre-approve a PET CT (78816).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a molecular pathology procedure provided on September 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for pathology services. You say that the patient clearly meeting the provider's criteria for testing. You say that you would like this approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for these services. The Plan says that the referring provider is also out-of-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 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 a molecular pathology procedure provided on September 20, 2019 by an out of network (OON) provider.