Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve Contour Next EZ (A4253).
You asked the Plan to pre-approve Contour Next EZ. You say that the requested items are necessary. The Plan denied your request. The Plan says that medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that MA plans may specify brands and manufacturers as preferred and charge lower cost sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Contour Next EZ have been met. Specifically, the Evidence of Coverage does not disclose the DME coverage limitations for the Plan preferred brands vs. non-preferred brands. The Plan therefore did not follow Medicare rules for specifying brands or manufacturers of DME. Therefore, we decided that the Plan has to pre-approve Contour Next EZ (A4253).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the physical therapy visits provided from
October 17, 2019 to December 16, 2019.
You asked the Plan to waive the copayment for the physical therapy visits. You say that you believed you were
being charged for specialist office visits. You say the charge would be unfair. The Plan denied your request.
The Plan says you have been charged the correct cost sharing 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 $30
copayment for each Medicare-covered visit.
You have been asked to pay a $30 copayment for each of the physical therapy visits. The physical therapy
visits fall within the "Outpatient rehabilitation services" 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 physical therapy visits provided from October 17, 2019 to December 16, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care from May 9, 2018 through May 11,
2018.
You asked the Plan to pay for inpatient hospital care. You say that you are requesting a review of the claim for
inpatient authorization. The Plan denied your request. The Plan says there was an authorization approved for
observation services and non-participating providers require an authorization for inpatient services. The Plan
states no authorization was obtained for an inpatient stay.
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 inpatient hospital care from May 9, 2018 through
May 11, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) and the mechanical traction
therapy (97012) provided August 5, 2019 to August 8, 2019.
You asked the Plan to pay for the therapeutic exercises and the mechanical traction therapy. You say that you
are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says
these services are not a covered benefit under the enrollee's contractual policy.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided
that the Plan does not have to pay for the therapeutic exercises (97110) and the mechanical traction therapy
(97012) provided August 5, 2019 to August 8, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT Scan of the head/brain (70450) provided on November 3, 2019.
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration because the member had multiple services on the same date of service. The Plan denied your request. The Plan says services that are considered column II procedures to another service are not eligible for reimbursement when billed with the column I procedure code.
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, we have confirmed that code the CT Scan has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for a CT Scan of the head/brain (70450) provided on November 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye exam provided on November 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an eye exam. You say that you thought that your Plan would pay for these services. The Plan denied your request. The Plan says no prior authorization was obtained.
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 an eye exam provided on November 23, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from August 13, 2019 to September 11, 2019.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not require any skilled services that could not have been provided in an alternate setting other than a SNF.
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 August 13, 2019 to September 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for over-the-counter (OTC) drugs (A9150) purchased on November 21, 2019.
You asked the Plan to pay for OTC drugs. You say that you needed these items for a colonoscopy that you did not receive. The Plan denied your request. The Plan says these items are not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and OTC drugs is an OTC item. Therefore, we decided that the Plan does not have to pay for over-the-counter (OTC) drugs (A9150) purchased on November 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from November 11,
2019 through November 19, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your
cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim
was processed accordingly with your 2019 EOC benefits.
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 shows that you were admitted on November 11, 2019 and discharged on November 19,
2019. You were asked to pay a $325 copayment per day from November 11, 2019 through November 15, 2019,
days 1-5 of your inpatient stay. There were no copayment charges from November 16, 2019, day 6 of your
inpatient hospital care until your day of discharge November 19, 2019. Per your contract there is a $325
copayment per day required for days 1-5. 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 inpatient
hospital care from November 11, 2019 through November 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Imfinzi (J9173) for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the medical records submitted indicate stage IIB disease, with progression of disease
after chemoradiation therapy, per the CT scan of 3/4/20.
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 drug. Our reviewer says that the
requested drug is not medically reasonable or necessary. Our physician reviewer found submitted
documentation, Medicare guidelines, and Medicare approved compendia were considered. Submitted
documentation notes the enrollee's condition stge IIB. Review of the submitted documentation notes the
enrollee underwent a right upper lobe resection. Compendia notes the requested medication is used for the
treatment of unresectable stage III NSCLC without disease progression following 2 cycles of platinum-based
chemotherapy and concurrent radiation therapy within 42 days of study initiation. The provider noted a
computed tomography study 3.2020 documented disease progression with new lung lesion and nodal
progression. Without the support of the documentation, medical necessity cannot be determined.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have
to pre-approve Imfinzi (J9173) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for custom fabricated oral appliance used for the treatment of
obstructive sleep apnea (E0486).
You asked the Plan to pay for custom fabricated oral appliance. You say that you were told by the dentist who
fitted you for this appliance that it was the only one that Medicare would approve however the plan only paid
about $135 and you paid the bulk of the cost. The Plan denied your request. The Plan says this claim was
processed correctly and the correct coinsurance was applied.
The rules say that a Cost plan must disclose in writing all benefits available under the Plan. The health plan
contract says that enrollees must pay 30% of the cost for Durable medical equipment (DME) and related
supplies provided by an out of network provider.
You have been asked to pay $150 coinsurance for the custom fabricated oral appliance. The records show the
plan allowed the maximum of $500 and paid $350. The custom fabricated oral appliance falls within the
Durable medical equipment (DME) and related supplies 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 pay for
custom fabricated oral appliance used for the treatment of obstructive sleep apnea (E0486).
Your complaint about the device not fitting correctly or helping your sleep apnea condition and wanting a
refund is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve CT scan of the heart, including 3D image post processing.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says that the clinical information provided describes a high pretest probability for coronary
artery disease.
The Plan must follow Medicare rules. Medicare rules say that CT 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 scan. Our reviewer says that the
requested scan is medically reasonable and necessary. Our physician reviewer found you have an equivocal
stress test because of the ventricular ectopy but no other high risk feature described on the stress test. Your
blood pressure and LV function are normal as well. Given these findings, the pretest probability of CAD is
actually low/intermediate, not high as the Health Plan contends. Therefore CT angiography is a reasonable and
indicated test to rule out significant CAD in a lower risk patient based on both published guidelines and the
Medicare NCD.
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 scan have been met. Therefore, we decided that the Plan has to pre-approve
CT scan of the heart, including 3D image post processing.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visits provided from February 6,
2019 through September 18, 2019.
You asked the Plan to waive the copayment for the office visits. You say that this is your primary care
physician for your mental health. You say that the copayment should be $10. The Plan denied your request.
The Plan says the copayments applied 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 $40
copayment for each Medicare-covered individual or group therapy office visit.
You have been asked to pay a $40 copayment for each office visit. The total amount you owe is $160 ($40/visit
x 4 visits = $160). The office visits fall within the "Outpatient mental health care" 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 office visits provided from February 6, 2019 through September
18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from October 15, 2019 through October 22, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
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 shows that you were admitted on October 15, 2019 and discharged on October 22, 2019. You were asked to pay a $175 copayment per day from October 15, 2019 through October 19, 2019, days 1-5 of your inpatient stay. There were no copayment charges from October 20, 2019, day 6 of your inpatient hospital care until your day of discharge October 22, 2019. Per your contract there is a $175 copayment per day required for days 1-5. 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 inpatient hospital care from October 15, 2019 through October 22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network testing services provided on September 4,
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 enrollee did not have prior authorization for out of network care and the ordering
physician was not in network.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan must 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 out of network testing services provided on
September 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrocardiogram (EKG) rendered to the enrollee on September 15, 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 93010 is not supported.
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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010 is not supported in the medical record. Specifically, there are no submitted records for the date of service at issue to support that the EKG was performed as billed. The records show that the interpretation and report were performed on September 16, 2019. 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 for the electrocardiogram (EKG) rendered to the enrollee on September 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injection provided on November 7, 2019.
You asked the Plan to waive the coinsurance for the Part B injection. You say that you were told the injection was covered. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 20% of the total cost for Medicare-covered chemotherapy drugs and other Medicare-covered Part B prescription drugs. You have been asked to pay $224.28 which is 20% of the allowed amount for the Part B injection. The allowed amount is $1,121.40. ($1,121.40 x 20% = $224.28). The Part B injection 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 coinsurance for the Part B injection provided on November 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 7, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you would like this appeal reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained.
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 an office visit provided on November 7, 2019 by an out of network (OON) provider.