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

We decided that the Plan does not have to pay for a biopsy and ultrasonic guidance for needle placement provided on May 31, 2019.
You asked the Plan to pay for the biopsy and ultrasonic guidance for needle placement. The Plan denied your request. The Plan says that the 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 been documented.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for a biopsy and ultrasonic guidance for needle placement provided on May 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rest home visit provided on March 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 rest home visit provided on March 22, 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 a waiver or reduction of copayments forcardiology office visits.You asked the Plan to pre-approve a waiver or reduction of copayments forspecialist visits. You say thatyou are on a fixed income and these copayments are very hard for you financially.The Plan denied your request. The Plan says your cost-sharing responsibility is $40 copayment for each specialist visit.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 $40 copayment for each specialist visit.You are being asked to pay $40 copayment for each specialist visit. Specialist visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. 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 pre-approve a waiver or reduction of copayments forcardiology office visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids purchased on September 11, 2019 from a noncontracted
provider.
You asked the Plan to pay for the hearing aids. You say that your hearing has gotten significantly worse over
the past two years and you needed to get larger updated, stronger hearing aids. The Plan denied your request.
The Plan says you purchased hearing aids in 2016 that were partially covered ($1000) by the Plan and the
benefit for purchasing new hearing aids is limited to $1000 every 60 months.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case.
We looked at the file, and the Plan's rules. You purchased hearing aids in 2016 that were partially covered
($1000) by the Plan and the benefit for purchasing new hearing aids is limited to $1000 every 60 months.
Therefore, we decided that the Plan does not have to pay for hearing aids purchased on September 11, 2019
from a non-contracted provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. The Plan denied your request. The Plan says that the enrollee has not met step therapy criteria.
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 Prolia. Our reviewer says that Prolia is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed zoledronic acid or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Prolia. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).
You asked the Plan to pre-approve Prolia. You say that the requested medication is necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has 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 Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that zoledronic acid would likely be less effective, and/or would likely have adverse effects for you 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 Prolia have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient lab tests provided on August 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for outpatient lab tests. You say that you would not have had these tests done if you knew you needed a referral. The Plan denied your request. The Plan says there is no referral on file 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 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 outpatient lab tests provided on August 6, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation therapy (36475, 36473).You asked the Plan to pre-approve endovenous ablation therapy. You say that the services are 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 (ERFA) (EVLT) are covered when specific 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 endovenous ablation therapy. Our reviewer says that the services are not medically necessary. Our physician reviewer found there are no vascular studies to show that this enrollee does not have extensive peripheral artery disease (PAD) as suggested by documentation of PAD and physical exam findings of cyanotic toes L>right. The requested endovascular ablation is contraindicated in the setting of PAD.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endovenous ablation therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveendovenous ablation therapy (36475, 36473).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve POV, group 1 heavy duty, patient weight capacity 301
to 450 pounds (CPT Code K0801). You asked the Plan to pre-approve the POV. You say that the current scooter is too big and heavy to take apart due to having a small car. You state that your home is too small for the current scooter. The Plan denied your
request. The Plan says the Medicare rules have not been met. The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the POV have not been met. Based on the received information, your mobility related activities of daily living inside your home could be met with a standard power scooter. In addition, heavy duty powered wheelchairs or scooters are provided for members who need a powered mobility
assistance device and weigh 285 to 400 pounds, and you weigh 130 pounds. Therefore, we decided that the Plan does not have to pre-approve POV, group 1 heavy duty, patient weight capacity 301 to 450 pounds (CPT Code K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral ankle foot orthoses (CPT Code L1971) provided to the enrollee on May 3, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthoses have not been met. The medical record shows that the enrollee was seen by the provider on February 18, 2019 where he documented a full office visit and physical exam. There is no mention in the records of any ankle or foot pain or limitation of movement of the ankle/foot. There is no mention of the need for ankle/foot bracing. There is no commensurate note in the medical record on or around that date as to why the brace was being ordered. Therefore, we decided that the Plan does not have to pay for bilateral ankle foot orthoses (CPT Code L1971) provided to the enrollee on May 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from LTACH care. The Plan denied your request. The Plan says LTACH provide no benefit over continued care in the short term hospital.
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 patient is currently undergoing treatment at an ACH for a small bowel obstruction. The enrollee underwent several surgeries, which have been complicated by the development of an EC fistula and abdominal abscess. The enrollee is not currently intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs. 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-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for a catheter placement surgery (93458) and a lipid panel blood test (80061) provided on February 1, 2018.
You asked the Plan to waive the cost-sharing for a catheter placement surgery and a lipid panel blood test. You say that these charges should be reduced or eliminated. The Plan denied your request. The Plan says these services 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 $10 copayment for Medicare-covered lab services and a 20% coinsurance for Medicare-covered surgery.
You have been asked to pay $663.57 (3,317.85 allowed amount x 20% = $663.57) for a catheter placement surgery and $10 for a lipid panel blood test, which is a lab service. 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 cost-sharing for a catheter placement surgery (93458) and a lipid panel blood test (80061) provided on February 1, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 17, 2019 to the enrollee 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-participating 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 October 17, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Minivelle Topical Solution.
You asked the Plan to pre-approve the Minivelle. You say that the drug is medically necessary. The Plan
denied your request. The Plan says the topical solution is self-administered and is not eligible for coverage
under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Minivelle Topical Solution.
Benefits for the Minivelle 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Butalbital, Acetaminophen, And Caffeine 50-325-40
tablets.
You asked the Plan to pre-approve Butalbital, Acetaminophen, And Caffeine. You say that the drug is
medically necessary. The Plan denied your request. The Plan says the oral medication is not eligible for
coverage under the Part B medical benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
drugs. The self-administered drugs requested here are not among the types which are covered by
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Butalbital, Acetaminophen,
And Caffeine 50-325-40 tablets.
Benefits for Butalbital, Acetaminophen, And Caffeine 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulicity 1.5 MG/0.5 ML pen.
You asked the Plan to pre-approve Trulicity. You say that the medication is medically necessary. The Plan denied your request. The Plan says this medication is a type of self-administered drugs that is not eligible for coverage under the Part B medical 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-approve Trulicity 1.5 MG/0.5 ML pen.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for CPT code 71045 provided on July 31, 2019.
You asked the Plan to pay for CPT code 71045. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that payment for CPT code 71045 is included in the payment for another procedure.
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 case file does not contain evidence that CPT code 71045 cannot be paid as it was billed, according to Medicare rules. The file does not contain a copy of a claim that contains the CPT code 74022 that the health plan states CPT code 71045 is bundled with. It cannot be verified that payment for CPT code 71045 is bundled with another procedure that was billed on the same date of service. Therefore, we decided that the Plan has to pay for CPT code 71045 provided on July 31, 2019.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services provided on September 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to receive 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 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 physician services provided on September 18, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered to the enrollee on August 12, 2019.
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 procedure code 99231 is not covered.
The Plan must follow Medicare rules. The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 99231 and 01480. Code 99231 is a column II code with a modifier indicator of 1 when billed with column I code 01480. Code 99231 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered to the enrollee on August 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for portable oxygen concentrator rental (E1392NU) provided by a non-contracted medical supplier, on December 21, 2018.
You asked the Plan to pay for the DME. You say that your children bought paid for the oxygen concentrator and did not realize that a referral or pre-authorization was needed to make the purchase. You state the metal cylinders are too heavy to pick up and put in the car when leaving home for trips or walking anywhere. The Plan denied your request. The Plan says the Medicare rules have not been met.
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. Your provider must get an approval from the plan before the member is able to get some DME and the DME must be obtained through participating plan suppliers. This is called getting a prior authorization. In addition, Medicare guidelines stipulate that reimbursement for oxygen equipment is limited to 36 monthly rental payments. There is no further payment for oxygen equipment during the 5-year reasonable useful lifetime (RUL) of the equipment after 36 rental payments have been made. You obtained the portable oxygen concentrator on a purchase basis, in lieu of a rental, with the purchase being made from a DME provider not contracted with your health plan. Therefore, we decided that the Plan does not have to pay for portable oxygen concentrator rental (E1392NU) provided by a non-contracted medical supplier, on December 21, 2018.