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 you by an out-of-network provider on January 31, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the servicesat 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 youby an out-of-network provider on January 31, 2020.
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 transfer to an LTACH is medically
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met.
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
Long term acute care hospitals (LTACHs) are certified as acute care hospitals, and in general, LTACHs do not
provide clinical services that are materially different than those of short-term acute care hospitals. In this case,
ongoing care needs include tracheostomy care, telemetry, seizure precautions, surveillance laboratory studies,
antibiotics, scheduled hemodialysis, tube feedings, and therapy services. The documentation does not support
that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital
where he is currently receiving care. There are no required medical services identified that are available at the
LTACH, that are not available at the current health care setting being offered by the health plan. Consequently,
the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and
condition of the enrollee at this time.
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: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an Ambulance Transport and Emergency Room services (70450, A0425, A0427, 99285) provided March 13 to March 14, 2020.
You asked the Plan to waive the copayments for the Ambulance Transport and Emergency Room services. You say that the copayments should be waived. The Plan denied your request. The Plan says the correct copayments were 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 Emergency Care and a $225 copayment for Ambulance Services. You have been asked to pay a $90 copayment for the Emergency Room visit and a $225 copayment for the Ambulance Transport. 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 an Ambulance Transport and Emergency Room services (70450, A0425, A0427, 99285) provided March 13 to March 14, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the mechanical traction therapy (97012) provided
February 17, 2020 to February 21, 2020.
You asked the Plan to pay for these services. 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 your 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 mechanical traction therapy (97012) provided February 17, 2020 to February 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for enhanced eyeglass lenses for progressive lenses, anti-reflective coating per lens, tint per lens provided on March 5, 2020.
You asked the Plan to pay for the enhanced eyeglass lenses. You say that an employee at the optometrist office advised you that the type of enhancements you received would be covered by your insurance plan. The Plan denied your request. The Plan says enhancements are not covered through the allowance but may be purchased at an additional cost.
Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear 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 eyeglasses you received are enhanced eyewear. The Plan does not cover enhancements under your vision benefit. Therefore, we decided that the Plan does not have to pay for enhanced eyeglass lenses for progressive lenses, anti-reflective coating per lens, tint per lens provided on March 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient mental health services provided on January 14,
2020 by an out of network (OON) provider.
You asked the Plan to pay for outpatient mental health services. You say that you would like this claim
reprocessed and approved in payment. The Plan denied your request. The Plan says prior authorization was not
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 outpatient mental health services provided on
January 14, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on
September 10, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that you should be
reimbursed for this claim. 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 provider and professional services at an in-network specialist's office.
You have been asked to pay a $30 copayment for the specialist office visit. The specialist office visit falls
within the specialist's "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 copayment for the specialist office visit provided on September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forlaboratory services provided on March 12, 2020.You asked the Plan to waive the copayment forlaboratory services. 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 you must pay a $10 copayment for laboratory tests. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall 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 forlaboratory services provided on March 12, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve proton beam therapy.You asked the Plan to pre-approve proton beam therapy. You say that you are appealing with medical records.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the potential benefit of proton beam therapy over non-proton based radiation is investigational and therefore not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are 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 pre-approve proton beam therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based upon the provided records, it is not plausible that proton beam therapy would provide a clinically meaningful benefit over a well-designed intensity modulated radiation therapy (IMRT) plan. While proton beam therapy is not experimental, its potential benefit over non-proton based radiation is investigational. Thus, proton beam therapy is not medically necessary as it would not meet ASTRO or National Comprehensive Cancer Network (NCCN) criteria and therefore would not be furnished in accordance with accepted standards of care.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy have not been met.Therefore, we decided that the Plan does not have to pre-approve proton beam therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 17, 2020 to January 27, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient visit (99204). You say that you would like reconsideration because the provider performing services in a nursing home facility is not responsible for obtaining authorization. The Plan denied your request. The Plan says prior authorization was not obtained by the provider or facility.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the medical services provided on January 17, 2020 to January 27, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Evenity.
You asked the Plan to pre-approve Evenity. You say that the medication has been proven to build bone mass and prevent fractures. The Plan denied your request. The Plan says injectable medications are covered under the medical benefit if furnished by the physician.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Evenity.
Benefits for Evenity 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
You asked the Plan to pre-approve continuous glucose monitor. You say that when you use a needle there is not enough blood coming out, so you need to try several times. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you are not administering insulin and therefore do not meet the Medicare criteria for a continuous glucose monitor.
The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are devices which meet the above criteria, and may be covered by Medicare when considered 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 continuous glucose monitor. Our reviewer says that you do not meet the Medicare criteria for the requested continuous glucose monitor. Our physician reviewer found you are not taking any medication or treatment plan which requires multiple glucose readings each day or treatment adjustments to justify a continuous glucose monitor. There is no report of you trying and failing other lancet types. Therefore, this request is not medically necessary at this time. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the electrical stimulation (G0283) provided on March 10, 2020.You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says this service is not a covered benefit under your 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 service at issue is not manual manipulation of the spine.Therefore, we decided that the Plan does not have to pay for the electrical stimulation (G0283) provided on March 10, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 28, 2019 by an out of network (OON) provider.You asked the Plan to pay for the rest home visit (99336) provided on June 28, 2019.. You say that you would like reconsideration because this provider rendered medically necessary services in good faith.The Plan denied your request. The Plan says utilization of network provider is required when possible and available.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.Therefore, we decided that the Plan does not have to pay for the medical services provided on June 28, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copaymentfor the inpatient hospital care provided January 17, 2020 to January 21, 2020.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 services 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 $275 copayment each day for days 1-6, for Medicare-covered hospital care. Youpay a $0 copayment for additional Medicare-covered days. You have been asked to pay a $1,100 copayment ($275 x 4days) for inpatient hospital care. 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 copaymentfor the inpatient hospital care provided January 17, 2020 to January 21, 2020
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveFreestyle Libre 14 day reader.You asked the Plan to pre-approveFreestyle Libre 14 day reader. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested item is not a covered benefit.The Plan must follow Medicare rules. Medicare rules say that CGMs and CGM supplies are only covered when enrollees are using a blood glucose monitor or continuous glucose monitoring system and testing their blood sugar four or more times a day. CGMs and CGM supplies are only covered when enrollees are insulin treated with multiple (three or more) daily injections of insulin or using a Medicare covered continuous subcutaneousinsulin infusion pump.We looked at the file and Medicare rules. The documentation shows that you only test your blood sugar three times a day. In addition, you only do one daily injections of Toujeo. Based on this information, we decided that Medicare rules for coverage of Freestyle Libre 14 day reader have not been met.Therefore, wedecided that the Plan does not have to pre-approveFreestyle Libre 14 day reader.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit services to be provided by an out of
network (OON) provider.
You asked the Plan to pre-approve the office visit services. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent
to seek out-of-network care. The Plan says there are equally qualified in-network Orthopedist's available to you
that can provide the treatment you are requesting.
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
the office visit services to be provided by an out of network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the nerve conduction study and the muscle
testing provided on February 20, 2020.
You asked the Plan to reduce the copayment for the nerve conduction study and the muscle testing. You say
that you will only pay the $5 copayment as your insurance card says. 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 $200
copayment for all other Medicare-covered diagnostic procedures and tests.
You have been asked to pay a $200 copayment for the nerve conduction study and the muscle testing. The
nerve conduction study and the muscle testing fall 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 reduce the copayment for the nerve
conduction study and muscle testing provided on February 20, 2020.