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

We decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 12, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were not authorized.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 services.Therefore, we decided that the Plan does not have to pay forthe medical services provided to the enrollee by an out-of-network provider on September 12, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forProtein Electrophoretic Fractionation (84165) provided by on October 11, 2019.You asked the Plan to pay forthe lab services. You say that services were medically necessary.The Plan denied your request. The Plan says the records provided were for a different provider.The Plan must follow Medicare rules. Medicare rules say that providers must provide sufficient documentation to the plan to furnish payment. We looked at the file and Medicare rules. Only limited records from a different provider were submitted for review. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met.Therefore, we decided that the Plan does not have to pay forProtein Electrophoretic Fractionation (84165) provided on October 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the requested admission to a LTACH is medically necessary.The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care on 2/10/20 for shortness of breath with productive cough, chest x-ray revealed mild pulmonary edema and slight effusion with bilateral infiltrates. The member is on 2L NC at baseline. Member was seen the week before at her PCP's office due to not feeling well, and was discharged home from PCP and 2 days later started to get sick, and short of breath.At the time of the request, the member's status is stable. She is on high flow oxygen and CPAP. The member is receiving medically necessary acute and/or critical care. The member does not have clinical conditions that cannot be appropriately treated in the current hospital, and there are no issues for which LTACH may offer a therapeutic advantage.The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met.Therefore, we decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Outpatient Mental Health
Decision: Favorable

We decided that the Plan has to pre-approvea psychological evaluation for spinal cord stimulator (SCS) placement.You asked the Plan to pre-approvethese services. You say that you need the evaluation for a spinal cord stimulator.The Plan denied your request. The Plan says that the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that if there are no specificcoverage rules for an item or service, then that item or service will be covered when it is 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 correctin denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the submitted records show that you have major depressive disorder and anxiety disorder and are requesting an evaluation prior to SCS implantation. You have pain after breaking your left ankle 22 years prior. You have tried acupuncture and several pain medications. Although you had a prior SCS, the records support that a psychological evaluation is reasonable and medically necessary for consideration of a new SCS implantation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met.Therefore, we decided that the Plan has to pre-approvea psychological evaluation for spinal cord stimulator (SCS) placement. 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 believethere was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvePrivigen for the enrollee.You asked the Plan to pre-approvePrivigen. You say that this is medically necessary.The Plan denied your request. The Plan says that the requested indication is not approved by the FDA and not supported by one or more citations included in the listed compendia.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 Privigen. Our reviewer says that Privigen is not medically reasonable and necessary for the enrollee in this case. The enrollee has a diagnosis of an anti-MAG neuropathy (Immunoglobulin M(IgM) Anti-Myelin Associated Glycoprotein Peripheral Neuropathy). The enrollee is said to have previously had a treatment trial of Rituximab without benefit. The requested medication IVIG (Privigen) is not FDA approved for use in the patient's condition. Nor is it readily supported for use in the Medicare Accepted Compendia. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Privigen.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Privigen have not been met.Therefore, we decided that the Plan does not have to pre-approvePrivigen for the enrollee
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services arenecessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but the enrollee does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveEntresto 49mg-51mg tablet for the enrollee.You asked the Planto pre-approvethe drug. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is a drug that is taken orally.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 Plandoes not haveto pre-approveEntresto 49mg-51mg tablet for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D2950, D2954, D3310, D6740, D6245).You asked the Planto pre-approvethe services. You say that you are in need of a bridge, as you have had some teeth that are broken.The Plandenied your request. The Plansaysthese services are not covered by Medicare -therefore it is also not covered by the plan.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 inexcess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvedental services (D2950, D2954, D3310, D6740, D6245).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran outpatient clinic visit (G0463) provided by on October 22, 2019.You asked the Planto waive the copayment forthe clinic visit. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 $90 copayment for outpatient urgent care or Emergency Room visits. You have been asked to pay a $90 copayment forthe clinic visit. the clinic visit falls within the outpatient urgent care or Emergency Room visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran outpatient clinic visit (G0463) provided by on October 22, 2019.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay forthe acute inpatient hospital care provided on October 19, 2019l.You asked the Plan to pay foracute inpatient hospital care. You say that the hospital care was medically necessary and you were out of state on a trip during thehospital visit.The Plan denied your request. The Plan says that the hospital admission was not necessary and the hospital is not a network facility.The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. The enrollee presented to the Emergency Room. The services at issue were medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met.Therefore, we decided that the Plan has to pay forthe acute inpatient hospital care provided on October 19, 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 toopen the case again, we will send you a letter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the emergency room services you received on
December 23, 2019.
You asked the Plan to waive the copay for the services provided. You say that the hospital did not do anything
for you on the date of service. The Plan denied your request. The Plan says the claim was processed
appropriately based on your plan 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). Your contract with the Plan clearly says that you must pay a $90
copay for emergency care.
You have been asked to pay a $66.86 copay for the services provided. Because the amount is less than your
$90 copay, you were charged the lesser amount. Although the ultimate goal of unpacking your wound was not
provided, services were rendered on the date of service at issue. The services fall within the emergency 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 copay for the emergency room services you
received on December 23, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 70450) provided to the enrollee on August 5, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this is a duplicate service.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The services in question were billed on a claim that is considered to be a duplicate of a claim previously processed and paid by the plan. This claim is not eligible for payment. Based on this information,we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 70450) provided to the enrollee on August 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean Optunedevice (CPT E0766).You asked the Plan to pre-approvethe Optune device. You say that the requested device is medically necessary.The Plan denied your request. The Plan says the request does not meet the guidelines for coverage.The Plan must follow Medicare rules. Medicare rules say that tumor treatment field therapy is covered for the treatment of newly diagnosed Glioblastoma Multiforme (GBM). We looked at the file and Medicare rules. The records do not show that the enrollee has GBM. Based on this information, we decided that Medicare rules for coverage of the Optune device have not been met.Therefore, we decided that the Plan does not have to pre-approvean Optune device (CPT E0766).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forComputed Tomography (CT) of the Abdomen and Pelvis (74177) provided November 15, 2019. You asked the Plan to waive the copayment forthe CT scan. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost share was applied.The rules say aplan 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 $225 copayment for Advanced Imaging. You have been asked to pay a $225 copayment for the CT scan. The CT scan falls within the Advanced Imaging 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 obligationyou agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forComputed Tomography (CT) of the Abdomen and Pelvis (74177) provided November 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora transthoracic echocardiography (TTE) test provided on July 23, 2019.You asked the Plan to pay forTTE test. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the service was not urgent or emergent in nature.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  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 TTE test. Our reviewer says that this service does not meet the Medicare criteria for urgent out-of-area care. Our physician reviewer found the need for this service could have been foreseen prior to leaving the Plan's service area. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of TTE test have not been met. Therefore, we decided that the Plan does not have to pay fora transthoracic echocardiography (TTE) test provided on July 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copays forthe urgent services you received on October 15, 2019 and October 18, 2019.You asked the Plan to waive the copays forthe services provided. You say that you should not have the copays because your primary care physician was not available.The Plan denied your request. The Plan says the copays apply per your plan 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). Your contract with the Plan clearly says that you must pay a $25 copay for each Medicare-covered office visit to other providers for urgently needed services. You have been asked to pay a $25 copay for each date of service. The services fall within the urgently needed 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 copays forthe urgent services you received on October 15, 2019 and October 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 24, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that the claim is reimbursable just as in-network claims.The Plan denied your request. The Plan says there is no valid referral for the service in question.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 services. Therefore, we decided that the Plan does not have to pay forthe medical services provided on September 24, 2019 by an out of network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora mammogram (G0279, 77066) provided November 26, 2019 .You asked the Plan to waive the copayment forthe mammogram. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.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 $50 copayment for Basic Imaging. You have been asked to pay a $50 copayment for the mammogram. The mammogram falls within the Basic Imaging 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 thecopayment fora mammogram (G0279, 77066) provided November 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran X-ray of the Shoulder (73030LT) provided on November 14, 2019. You asked the Planto waive the copayment forthe X-ray. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct cost sharing was applied.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 $50 copayment for X-rays done in the outpatient hospital setting. You have been asked to pay a $50 copayment for the X-ray. The X-ray falls within the X-rays done in the outpatient hospital setting 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 foran X-ray of the Shoulder (73030LT) provided on November 14, 2019.