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

We decided that the Plan does not have to pre-approveTrulicity 0.75mg/0.5ml pen (J3490).You asked the Plan to pre-approveTrulicity 0.75mg/0.5ml pen. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.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-approveTrulicity 0.75mg/0.5ml pen (J3490).Benefits for Trulicity 0.75mg/0.5ml penmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you an additional amount of the cost of hearing aids provided on November 14, 2019.You asked the Plan to reimburse you an additional amount of the cost of the hearing aids. The Plan denied your request.The Plan says the claim process correctly per your hearing aid benefit out-of-network.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. The file shows that the Plan reimbursed you the correct amount for the hearing aids based on the out-of-network hearing aid benefit.Therefore, we decided that the Plan does not have to reimburse you an additional amount of the cost of hearing aids provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on October 2, 2019 by an out of network (OON) provider. You asked the Plan to pay for the OON services. You say that the nursing home is responsible for obtaining prior authorization. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee on October 2, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lab services provided to the enrollee on November 6, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain 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 OON services.Therefore, we decided that the Plan does not have to pay forthe lab services provided to the enrollee on November 6, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the androgen receptor gene analysis provided to the enrollee on October 23, 2019.
You asked the Plan to pay for the testing service. The Plan denied your request. The Plan says the service provided is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. In this case, the CPT Code Manual definition of code 81173 is AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence. We looked at the file, and Medicare rules. The rules say that the service is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the androgen receptor gene analysis provided to the enrollee on October 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forinpatienthospital care from November 29, 2019 through December 7, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received due to the quality of care.The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The Plan states infection is a known risk of surgery and they filed a quality of care complaint for you.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received inpatient hospital care from November 29, 2019 through December 7, 2019. You are askedto pay a $300 copayment for the admission. 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 forinpatient hospital care from November 29, 2019 through December 7, 2019
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entyvio.You asked the Plan to pre-approve Entyvio. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried Stelara as required by step therapy rules.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 Entyvio. Our reviewer says that the criteria for coverage of Entyvio have not been met. Our physician reviewer found the Plan requires a trial of Stelara before they will approve the requested drug. The documentation does not support that the enrollee has tried Stelara or that Stelara would likely be less effective 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 Entyvio have not been met.Therefore, we decided that the Plan does not have to pre-approve Entyvio.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe genetic testing provided on November 6, 2019.You asked the Plan to pay forthe genetic testing. 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 medically necessary.The Plan follows Medicare rules. Medicare rules say that genetic testing is only covered for certain indications.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the genetic testing. Our reviewer says that the documentation does not support that the genetic testing provided was medically reasonable or necessary. Our physician reviewer found no provider records have been submitted for review. The limited documentation included the laboratory requisition, which indicates that the enrollee has breast cancer. Therefore, there is no evidence to support that the provided service was medically necessary and reasonable to diagnose, treat or otherwise manage the enrollee's condition(s).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 genetic testing have not been met. Therefore, we decided that the Plan does not have to pay forthe genetic testing provided on November 6, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion services provided to the enrollee from December 11, 2019 to December 18, 2019.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 claim was submitted with an invalid status indicator.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code billed has a status code indicator of "I" which that does not allow payment on Medicare claims.Therefore, we decided that the Plan does not have to pay for home infusion services provided to the enrollee from December 11, 2019 to December 18, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for outpatient lab work provided by an out-of-network provider on June 7, 2019.
You asked the Plan to pay for outpatient lab work. You say that you do not agree with these charges. The Plan denied your request. The Plan says that the rendering provider is out-of-network. The Plan says that prior authorization was not obtained.
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. the plan has failed to send in a complete Evidence of Coverage. Therefore, we decided that the Plan has to pay for outpatient lab work provided by an out-of-network provider on June 7, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis services billed with CPT code 20611 for date of service August 9, 2019.
You asked the Plan to pay for the arthrocentesis services. You say that the records provided support that CPT code 20611 should be paid. The appellant says that the provider underlined the portion of the medical records that support the billed service. The Plan denied your request. The Plan says CPT code 20611 remains not supported. The Plan says that the documentation does not include documentation of permanently recorded images.
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, the CPT Code Manual definition of code 20611 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the arthrocentesis services. Our reviewer says that the provided records do not show that the services described by CPT code 20611 were provided on the date of service in dispute. Our physician reviewer found the enrollee presented two months' status post right shoulder rotator cuff repair with signs/symptoms of right shoulder adhesive capsulitis. A glenohumeral intra-articular Kenalog injection was performed under ultrasound guidance on August 9, 2019. There are no submitted permanent images to support the use of the 20611 code. The physician documented a glenohumeral joint injection under ultrasound guidance with no discussion of permanently recorded images. In the absence of documentation of permanently recorded images, CPT code 20610 would be supported for the August 9, 2019 procedure. 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 arthrocentesis services have not been met. Therefore, we decided that the Plan does not have to pay for arthrocentesis services billed with CPT code 20611 for date of service August 9, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance services.You asked the Plan to waive the copayment for the ambulance services. You say that you do not feel that you should have to pay this amount because you were taken out of the house against your will at the doctor's request.The Plan denied your request. The Plan says you were charged this cost sharing 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 $275 copayment for Medicare covered ambulance trips per day. You had 1 ambulance trip(s). The Plan charged you $275 for these services. 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 services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided to the enrollee from December 11, 2019 to December 18, 2019 under code S9328.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the code submitted on the claim has an invalid status code indicator for Medicare billing purposed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code billed has a status code indicator of "I" which that does not allow payment on Medicare claims.Therefore, we decided that the Plan does not have to pay forhome health services provided to the enrollee from December 11, 2019 to December 18, 2019 under code S9328.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 1, 2019 to May 18, 2019.

You asked the Plan to pay for the skilled nursing services. You say that the assessments and intervention were ongoing and SNF stay was necessary to prevent re-hospitalization. The Plan denied your request. The Plan says the antibiotics and wound care noted could have been managed at a lower level of care.

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 in denying the request to pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting

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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from May 1, 2019 to May 18, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat elevator (E2300) with power standing feature (E2301).
You asked the Plan to pre-approve the seat elevator with standing feature. You say that the accessories are medically necessary. The Plan denied your request. The Plan says the items are not a covered benefit.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a seat elevator (E2300) with power standing feature (E2301).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve general anesthesia, first 15 minutes (D9222) and general anesthesia, each subsequent 15 minutes (D9223).
You asked the Plan to pre-approve these services. You say that per the doctor's recommendation, all dental procedures requested are medically necessary. Additionally, you say that general anesthesia was requested due to the nature of the procedures. The Plan denied your request. The Plan says the requested services are not a covered benefit under the member's contractual dental policy.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve general anesthesia, first 15 minutes (D9222) and general anesthesia, each subsequent 15 minutes (D9223).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fornaturopathic services provided on October 15, 2019 on December 18, 2019.You asked the Plan to pay fornaturopathic services. You say that you would like reconsideration because these services are medically necessary.The Plan denied your request. The Plan says Naturopathic services are a benefit exclusion.The Plan must follow Medicare rules. The rules say that Medicare does not cover naturopathic services. The services at issue in this appeal are naturopathic services.Therefore, we decided that the Plan does not have to pay fornaturopathic services provided on October 15, 2019 on December 18, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve4 additionalhome health care hours 5 days a week and 12 additional hours 2 days a week.You asked the Plan to pre-approveadditional home health care hours. You say that the enrollee needs these services.The Plan denied your request. The Plan says this is not medically necessary.The Plan must follow Medicare rules. Medicare rules say that PACE plans must cover all services determined necessary by the IDT to improve and maintain the enrollee's overall health status.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 additional home health care hours. Our reviewer says that the requested services do not meet criteria for coverage. Our physician reviewer found the documentation indicates that the patient is not a high medical risk, is not at risk for elopement, and is able to carry out an emergency plan. She was approved for 12 hours 7 days a week in addition to 5 center days. She does not meet PACE guidelines for 24-hour supervision in the home and can be left alone if set up is received prior to caregiver leaving home. The documentation does not support that the requested services are services are necessary and reasonable to meet the patient's needs and to improve and maintain her overall health status.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional home health care hours havenot been met.Therefore, we decided that the Plan does not have to pre-approve4 additional home health care hours 5 days a week and 12 additional hours 2 days a week.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing services provided on November 27, 2019 by an out of network (OON) provider.You asked the Plan to pay for skilled nursing services. You say that the nursing home is responsible to obtain prior authorization for their patients, which should cover medical treatments by the provider.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring facility 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 skilled nursing services provided on November 27, 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 copayments forspecialist visits provided from January 24, 2018 to July 24, 2018.You asked the Plan to waive the copayments forspecialist visits. You say that you 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 MAPD 1000 members must pay a $30 copayment for specialist visits. You had specialist visits from January 24, 2018 to July 24, 2018 for a total of 3 visits. Therefore, you are responsible to pay a $30 copayment per each visit. The total amount you owe is: $90.You have been asked to pay the total copayment amount of $90 for specialist visits. Specialist visits 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 copayments forspecialist visits provided from January 24, 2018 to July 24, 2018.