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

We decided that the Plan does not have to pay foran office visit provided on February 17, 2020.You asked the Plan to pay foroffice visit. You say that your Plan has out-of-network benefits.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider has opted out of Medicare and cannot be paid directly or through reimbursement to you.The plan must follow Medicare rules. Medicare rules say that Medicare plans may not pay for services given by a physician or other practitioner who has opted out of Medicare. We looked at case file and the Medicare rules. We confirmed that the provider has opted out of Medicare. Based on this information, we decided that Medicare rules for coverage of office visit have not been met.Therefore, we decided that the Plan does not have to pay foran office visit provided on February 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveorthopedic shoes with custom inserts.You asked the Plan to pre-approvefoot orthotics. The Plan denied your request. The Plan says you do not meet the Medicare criteria for orthopedic footwear.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  The records do not show that you suffer from diabetic foot disease, or wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approveorthopedicshoes with custom inserts.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for lumbar-sacral orthosis (L0631) provided on December 12, 2019.You asked the Planto pay forthe lumbar-sacral orthosis. You say that you would like reconsideration because this supply is medically necessary.The Plan denied your request. The Plan says the submitted medical records indicate that a prefabricated lumbar-sacral orthosis back brace was measured and givento the patient, however does not include the detailed description of the brace that was dispensed to thepatient.The Plan must follow Medicare rules. Medicare rules say that for items requiring more than minimal self-adjustment by a qualified practitioner documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lumbar-sacral orthosis have not been met. Specifically, the record does not document a detailed description of the modifications necessary at the timeof fitting.Therefore, we decided that the Plan does not have to pay forlumbar-sacral orthosis (L0631) provided on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formental health services (H0035) provided on December 2, 2019 through December 12, 2019.You asked the Plan to pay forthe mental health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says per Medicare guidelines HCPCS code H0035 is not a valid code for Medicare 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.We find that CPT code H0035 is not supported in the record. Specifically, Per Medicare, HCPCS code H0035 has a status indicator of 5. This means that code H0035 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the mental health services have not been met.Therefore, we decided that the Plan does not have to pay formental health services (H0035) provided on December 2, 2019 through December 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on June 4, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on June 4, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for post-cataract eyeglasses provided on November 13, 2019.
You asked the Plan to pay for the post-cataract eyeglasses. The Plan denied your request. The Plan says members have up to 12 months after cataract surgery to receive coverage for cataract eyeglasses.
The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear. The contract with the Plan says that the Plan covers Medicare-covered eyewear within 12 months after each cataract surgery. We looked at the file, Medicare rules and the Plan's rules. The file shows that you had cataract surgery on January 26, 2017 and February 9, 2017, which is more than 12 months after cataract surgery. Therefore, we decided that the Plan does not have to pay for post-cataract eyeglasses provided on November 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that you require therapy to maintain normal function to live.The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Your medical status does not currently require intensive physician and nursing oversight only in an IRF. You may benefit from multiple therapies such as physical and occupational therapy but the documentation does not support that your functional status requires an intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided from March 4, 2020 through March 7, 2020 by an out-of-network provider.
You asked the Plan to pay for the dental services. You say that you called the Plan on March 4, 2020 before you went to the dentist to inquire about dentists that your insurance would cover. The Plan denied your request. The Plan says their records support that you contacted the Plan on February 26, 2020, and were provided with office listings, which did not include this 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. Review of the file show that you received the dental services from March 4, 2020 through March 7, 2020 provided by an out-of-network provider. Your EOC states, "to be covered in-network, you need to use a provider that is contracted with our dental vendor to provide supplemental dental services. Care rendered by a provider that is not part of our supplemental dental network is not covered." 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 dental services provided from March 4, 2020 through March 7, 2020 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on February 17, 2020.
You asked the Plan to waive the copayment for a specialist visit. You say that you were told that you would not owe anything for the services. 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 $20 copayment per visit to a specialist. You have been asked to pay a $20 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 on February 17, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approveCanakinumab injections (J0638). You asked the Plan to pre-approvethe Canakinumab injections. You say that this enrollee will likely not reach remission on Methotrexate alone, and the long-term steroid should be avoided. You also say that you recommend Canakinumab, which has recently been approved by the Food and Drug Administration (FDA) for adult-onset Still's Disease.The Plan denied your request. The Plan says that Canakinumab is not medically necessary.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 the Canakinumab injections. Our reviewer says that Canakinumab injections meets coverage criteria. Our physician reviewer found the documentation does support that the Canakinumab is medically reasonable and necessary for the enrollee. Our reviewer found that the documentation does support that the Canakinumab is safe and effective for the enrollee. The enrollee has been on treatment with Methotrexate and Prednisone since at least May 2020 with the most recent visit note of June 26, 2020 indicating continued symptoms necessitating an increase in Prednisone dose. Our physician reviewer also found that Canakinumab is FDA-approved for the treatment of adult-onset Still's 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 Canakinumab injections have been met.Therefore, we decided that the Plan has to pre-approveCanakinumab injections (J0638).If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveEuflexxa.You asked the Plan to pre-approveEuflexxa. The Plan denied your request. The Plan says the step therapy requirements have not been met.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 Euflexxa. Our reviewer says that the requested Euflexxa is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that based on the medically records provided, the enrollee has not tried and failed the required drug(s). There is no indication that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approveEuflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that an ESI is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic neck and low back pain associated with radiculopathy. She is status post an L5 to S1 interlaminar ESI on February 6, 2020. She reported 30 percent pain relief from the injection on February 17, 2020. There is no documentation of failure of four weeks of non-surgical, non-injection care. The enrollee does not meet the criteria for coverage of the requested ESI and the services are 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar epidural steroid injection (ESI).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve6 additional occupational therapy visits.You asked the Plan to pre-approve6 additional occupational therapy visits. You say that the enrollee needs tocontinue these services.The Plan denied your request. The Plan says these visits are not necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.We asked our physician reviewer tocarefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve 6 additional occupational therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the therapy records do not indicate the enrollee requires the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to safely and effectively be performed only by a therapist, or under the supervision of a therapist. The enrollee reports resolved diplopia, has been educated on a home exercise program. The requested services are not part of a maintenance program and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional occupational therapy visits have not been met.Therefore, we decided that the Plan does not have to pre-approve6additional occupational therapy visits.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Gelsyn-3.
You asked the Plan to pre-approve Gelsyn-3. The Plan denied your request. The Plan says the step therapy requirements have not been met.
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 Gelsyn-3. Our reviewer says that Gelsyn-3 is not medically reasonable and necessary for the enrollee in this case. Our physician reviewer found that the records provided do not show that the enrollee has not tried and failed the required drugs. There is no indication that the Plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Gelsyn-3 have not been met. Therefore, we decided that the Plan does not have to pre-approve Gelsyn-3.
Appeal type: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to pay forCPT 95870. We decided that the Plan does not have to pay forCPT 95938. You asked the Plan to pay forthe services. The Plan says that the services were billed incorrectly. We decided that the Planhas to pay forCPT 95870. The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the plan has not provided documentation or rationale regarding its decision to deny CPT 95870. Without supporting documentation, the plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay forCPT 95870. We also decided that the Plandoes not have to pay forCPT 95938.The Plan must follow Medicare rules. Medicare rules say thatA56773 provides a list of covered ICD-10 codes for CPT 95938.We looked at the file and Medicare rules. CPT 95938 was billed with diagnosis codes S22.060A and R29.6. CPT 95938 is not covered when billed with these diagnosis codes. Based on this information, we decided that Medicare rules for coverage of CPT 95938 have not been met. Therefore, we decided that the Plan does not have to pay forCPT 95938.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from November 1, 2019 to November 27, 2019.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you feel that the Plan should cover 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 $40 copayment for outpatient rehabilitation services. The enrollee received outpatient rehabilitation services from November 1, 2019 to November 27, 2019 for a total of 9 visits. Therefore, the enrollee is responsible to pay a $40 copayment per each visit. The total amount the enrollee owes: $40 (copayment) x 9 (outpatient rehabilitation services) = $360. The enrollee has been asked to pay the total copayment amount of $360 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for outpatient rehabilitation services provided from November 1, 2019 to November 27, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for outpatient rehabilitation services provided from December 2, 2019 to December 12, 2019.
You asked the Plan to waive the copayments for outpatient rehabilitation services. You say that you feel that the Plan should fully cover 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 $40 copayment for outpatient rehabilitation services. The enrollee received outpatient rehabilitation services from December 2, 2019 to December 12, 2019 for a total of 4 visits. Therefore, the enrollee is responsible to pay a $40 copayment per each visit. The total amount the enrollee owes is: $40 (copayment) x 4 (outpatient rehabilitation services) = $160. The enrollee has been asked to pay the total copayment amount of $160 for outpatient rehabilitation services. Outpatient rehabilitation services fall within the outpatient rehabilitation 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 copayments for outpatient rehabilitation services provided from December 2, 2019 to December 12, 2019.