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

We decided that the Plan does not have to pay for the office visit provided by an out-of-network provider.

You asked the Plan to pay for the office visit. You say that the visit was medically necessary. The Plan denied your request. The Plan says this provider is not a network provider with the Plan.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to 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 had network providers available who could have provided 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 office visit provided by an out-of-network provider.
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 you would like reconsideration because a LTACH will offer pulmonary rehab to wean you off of oxygen. The Plan denied your request. The Plan says the records do not show that you have completed your full hospital course.

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 there are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan.

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: Home Health
Decision: Favorable

We decided that the Plan has to pre-approve continued home health skilled nursing services.

You asked the Plan to pre-approve home health services. You say that you disagree with the denial. The Plan
denied your request. The Plan says that the services are not medically necessary.

The Plan must follow Medicare rules. The rules say that a NOMNC must be issued prior to discontinuing
coverage of home care services.

There is no evidence that a NOMNC has been issued saying that coverage is ending for the home care services
at issue in this appeal. The file contained a blank NOMNC but a signed, valid NOMNC was not submitted.
Therefore, we decided that the Plan has to pre-approve continued home health skilled nursing services.

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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all 4 quadrants.

You asked the Plan to pre-approve the dental services. You say that the enrollee needs these services. The Plan denied your request. The Plan says 1 deep cleaning is covered every 2 years per quadrant with 1 deep cleaning maintenance every 6 months. The Plan says that you received a regular cleaning less than 6 months ago. The Plan also says that the frequency limit has been exceeded.

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, deep cleanings are covered every 2 years, per quadrant, with 1 deep cleaning maintenance every 6 months. The record shows that you received prophylaxis, thus fulfilling the frequency limit for a 6 month period. Therefore, we decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4341) for all 4 quadrants.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network specialist.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says it is not medically necessary to see an out-of-network 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral to an out-of-network specialist.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport.

You asked the Plan to waive the copayment for the ambulance transport. You say that you were transferred due to the high number of patients at the hospital. You say that you did not have a choice in the matter and should not be responsible for the bill. The Plan denied your request. The Plan says the copayment 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 $250 for each one-way Medicare-covered ambulance transport.

You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show you were transported by ambulance to another hospital. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the lightweight wheelchair.

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 purchased from a non-Medicare provider.

The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are
furnished by a provider or supplier enrolled in the Medicare program.

The file shows that the services were purchased from a provider who was not Medicare-certified during the
dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the
lightweight wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Durolane, 20 mg (J7318).

You asked the Plan to pre-approve Durolane. You say that the enrollee has trialed and failed meloxicam and cortisone injections. The Plan denied your request. The Plan says the enrollee has not tried the preferred drugs, Monovisc and Orthovisc. The Plan also says that this request does not meet the Plan's Part B 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 Durolane. Our reviewer says that Durolane is not medically necessary. Our physician reviewer found the provided documentation does not show that the enrollee has tried and failed the required drugs, Monovisc and Orthovisc. The reviewer found that there is no indication that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. Therefore, the reviewer found that the requested drug, Durolane, is not medically reasonable or 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 Durolane have not been met. Therefore, we decided that the Plan does not have to pre-approve Durolane, 20 mg (J7318).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cytopathology (Pap test) (88141).

You asked the Plan to waive the copayment for the Pap test. You say that you should not be charged a separate copayment. The Plan denied your request. The Plan says that the claim for the separate charge was reprocessed and the copayment for this service was 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 $10 copayment for diagnostic lab services and diagnostic procedures and tests.

You have been asked to pay a $10 copayment for the Pap test. This service falls within the Outpatient diagnostic tests and therapeutic services and 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 waive the copayment for the cytopathology (Pap test) (88141).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation and prophylaxis.

You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that you would like these
services to be covered. The Plan denied your request. The Plan says the treating provider opted out of Medicare.

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 items or services are not
covered when they are received by a Medicare opt out provider. Therefore, we decided that the Plan does not
have to pay for the periodic oral evaluation and prophylaxis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the dental services to be rendered by an OON provider.

You asked the Plan to pre-approve the dental services. You say that you would like these services to be approved. The Plan denied your request. The Plan says the provider you have requested to see is OON. The Plan also says there are multiple in-network general dentist available in your service area that can provide the requested dental services.

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 items or services are not covered when they are received by anyone other than a participating general dentist. Therefore, we decided that the Plan does not have to pre-approve the dental services to be rendered by an OON provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60 MG/ML syringe.

You asked the Plan to pre-approve Prolia 60 MG/ML syringe. You say that you want to be treated with this drug. The Plan denied your request. The Plan says you have not first tried and had a contraindication or intolerance to oral and intravenous bisphosphonates.

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 60 MG/ML syringe. Our reviewer says that the drug is not medically necessary. Our physician reviewer found the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the plan's required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. The enrollee does not have a history of osteoporosis related fracture.

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 60 MG/ML syringe have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60 MG/ML syringe.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for arthrocentesis (20610).

You asked the Plan to pay for arthrocentesis. You say that you would like the Plan to pay for the service at issue. The Plan denied your request. The Plan says You have a $1000 annual deductible. Until you have paid the deductible amount, you must pay the full cost for most of your covered services.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 deductible for outpatient surgery.

The item or service you asked the Plan to pay for falls within the benefit category outpatient surgery. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for outpatient surgery. This cost sharing is a contractual obligation that had not been met at the time arthrocentesis. Therefore, we decided that the Plan does not have to pay for arthrocentesis (20610).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services.

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 claim was billed incorrectly.

The Plan must follow Medicare rules. The rules say that SNF claims must be billed with a valid PDPM HIPPS
code.

We looked at the file and Medicare rules. The file shows that the claim was not billed with a valid PDPM
HIPPS code. 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 skilled nursing facility (SNF)
services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic services to be provided by an out of network (OON) provider.

You asked the Plan to pre-approve the chiropractic services. You say that you need to see this out-of-network provider because the in-network chiropractors refuse to use the treatment method you want. The Plan denied your request. The Plan says there are chiropractors available in-network, and the requested treatment method is excluded from coverage. Only manual manipulation of the spine to correct subluxation is covered under Medicare.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The rules also say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The requested provider in this case is not a network provider with the Plan, and the records show that the service at issue is not manual manipulation of the spine. The Plan has network providers available who can provide chiropractic care. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the Medicare-excluded chiropractic services to be provided by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical boot (L3260).

You asked the Plan to pre-approve a surgical boot. You say that you need this to recover from surgery. The Plan denied your request. The Plan says this item is not a covered benefit.

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. 

Records show that you do not suffer from diabetic foot disease and you do not 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-approve a surgical boot (L3260).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vimpat.

You asked the Plan to pre-approve Vimpat. You say that this should be covered. The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's prescription drug plan.

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 Vimpat.

Benefits for Vimpat 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for infusions.

You asked the Plan to waive the copayments for infusions. You say that you were told that you would owe 20% coinsurance for the infusions. 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 $175 copayment for outpatient surgery, including services provided at hospital outpatient facilities.

You received infusions at an outpatient hospital facility. Therefore, you are responsible to pay a $175 copayment per each visit. The total amount you owe is: $175 (copayment) x 14 (infusions) = $2,450.

You have been asked to pay the total copayment amount of $2,450 for infusions. Infusions fall within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for infusions.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the remote imaging for detection of retinal disease (92227).

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.

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 diagnostic procedures and tests provided in a specialist's office.

You have been asked to pay a $13.07 copayment for the diagnostic procedure provided at a specialist's office. This is the Medicare allowable amount for the service provided, which is less than the applicable copayment. 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 remote imaging for detection of retinal disease (92227).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (72170).

You asked the Plan to pay for the x-ray. You say that the services were medically necessary. The Plan denied your request. The Plan says this code shares a bundled relationship with another code billed and is not separately payable.

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 72170 is not supported in the medical record. Specifically, CPT code 72170 shares a column I / column II relationship with CPT code 73502 which was billed on the same service date. Based on this information, we decided that Medicare rules for coverage of the x-ray have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (72170).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a continuous glucose monitor with supplies (K0553).

You asked the Plan to pay for the continuous glucose monitor with supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says the enrollee did not request these items. The documentation does not support the billed services.

The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.

The record does not contain a valid proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. There is no itemized shipping documentation. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor with supplies (K0553).