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

We decided that the Plan does not have to pre-approve Praluent. You asked the Plan to pre-approve Praluent. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says Praluent is not covered under the enrollee's Medicare Part B benefit. 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 Praluent.Benefits for Praluent 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthroscopy provided in an outpatient
hospital facility on September 30, 2019.
You asked the Plan to waive the copayment for arthroscopy. You say that you cannot afford 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 $0
copayment for any surgical procedures provided during a colorectal screening and a $400 copayment for all
other outpatient services.
You received arthroscopy at an outpatient hospital facility on September 30, 2019. Therefore, you are
responsible to pay the $400 copayment.
You have been asked to pay a $400 copayment for arthroscopy. Arthroscopy falls 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 copayment for arthroscopy provided in an outpatient hospital facility on
September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Superion procedure for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says there are currently no clinical indications for this technology.
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 the procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the requested spacer is considered experimental. More research is needed. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Superion procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for low-level laser therapy provided from July 24, 2019 to November 1, 2019. You asked the Plan to pay for low-level laser therapy. You say that these services were necessary for your quality of life. The Plan denied your request. The Plan says these services are not covered by Medicare or the Plan. The Plan must follow Medicare rules. Medicare rules say that low level laser light therapy (LLLT) is considered not reasonable and necessary and is not payable by Medicare. We looked at the file and Medicare rules. The service at issue is considered not reasonable and necessary under Medicare rules and is not covered. Based on this information, we decided that Medicare rules for coverage of low-level laser therapy have not been met. Therefore, we decided that the Plan does not have to pay for low-level laser therapy provided from July 24, 2019 to November 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the monthly rental of the ambulatory chemotherapy infusion pump provided on August 15, 2019. You asked the Plan to pay for the infusion pump monthly rental. You say that you do not have access to medical records but believe that this should be paid since it was ordered by the physician. The Plan denied your request. The Plan says this is not separately payable as these infusions are started in a physician's office. The Plan must follow Medicare rules. Medicare rules say that equipment used to infuse drugs when the infusion is started in the physician's office are not separately billable as durable medical equipment. You are requesting payment for rental of the pump used for this chemotherapy infusion. The records provided show that the enrollee begins infusion with the pump in the doctor's office. As such, separate payment for the equipment is not allowed. Therefore, we decided that the Plan does not have to pay for the monthly rental of the ambulatory chemotherapy infusion pump provided on August 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 10, 2019 by an out of network (OON) provider. You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says prior authorization was not obtained as required under the plan benefits. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the medical services provided on July 10, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the chiropractic manipulation rendered to you on September 26, 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 that the services are not covered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan states that the services are not covered; however, the file shows that the provider submitted a claim for procedure code 98940 (chiropractic manipulation of the spine). These services are covered by Medicare. The Plan has not provided any documentation or rules to support that these services are not covered. Therefore, we decided that the Plan has to pay for the chiropractic manipulation rendered to you on September 26, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 Prothrombin (81240) and F5 Factor V Leiden (81241) testing. You asked the Plan to pre-approve F2 Prothrombin (81240) and F5 Factor V Leiden (81241) testing. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the services are not covered. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. Medicare says testing of variants to the F5 and F2 genes are not covered except for pregnant patients. The file shows that you are not pregnant. Based on this information, we decided that Medicare rules for coverage of F2 Prothrombin (81240) and F5 Factor V Leiden (81241) have not been met. Therefore, we decided that the Plan does not have to pre-approve F2 Prothrombin (81240) and F5 Factor V Leiden (81241) testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on October 22, 2019.
You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says non-emergent,
non-urgent services with out-of-network providers require prior authorization.
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 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 for vision services provided on October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation therapy provided on November 6, 2019. You asked the Plan to waive the copayment for radiation therapy. You say that you cannot afford 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 $60 copayment for radiation therapy. You have been asked to pay a $60 copayment for radiation therapy. Radiation therapy 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 radiation therapy provided on November 6, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room Visit provided June 28, 2018 by the Hospital.
You asked the Plan to waive the copayment for the Emergency Room Visit. 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 $100 copayment for Emergency Care. You have been asked to pay a $100 copayment for the Emergency Room Visit. the Emergency Room Visit falls 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 copayment for an Emergency Room Visit provided June 28, 2018 by the Hospital.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 11, 2019 by an out of network (OON) provider. You asked the Plan to pay for physician services. You say that you feel that this claim was denied in error. 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 physician services provided on November 11, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 8, 2019 by an out of network provider. You asked the Plan to pay for the non-emergent ambulance service. You say that this was a medically necessary transport. The Plan denied your request. The Plan says you are an out-of-network provider and services were rendered without an authorization. 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 ambulance services provided on October 8, 2019 by an out of network provider.
Appeal type: Lab
Decision: Unfavorable

You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records do not show that the enrollee is homebound and/or confined to the home.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. 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 services. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the request for in-home blood extraction by a home health nurse is not medically necessary. Although you may be considered homebound, as you have a condition that makes you susceptible to COVID-19, the documentation does not meet Medicare criteria. There is no evidence that you are already receiving Medicare skilled home health services. There is no evidence that you are getting tested for COVID-19. Sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act specifically exclude venipuncture, as a basis for qualifying for Medicare home health services if this is the sole skilled service you require. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve in-home blood extraction by a home health nurse.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on December 10, 2019. You asked the Plan to pay for the ambulance services. You say that the enrollee was bed confined and the stretcher transportation was required to move the enrollee to the destination safely. The Plan denied your request. The Plan says these services are not a covered benefit. The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for the ambulance services provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on November 30, 2019. You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. 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 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 for nurse practitioner services provided on November 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that
were issued on March 9, 2019.
You asked the Plan to pay for the compression stockings. You say that the stockings were prescribed to reduce
risk for DVT. The Plan denied your request. The Plan says the enrollee does not have a qualifying wound or
lymphedema.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6530
are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that
compression bandages and gradient compression wraps are covered only when they are used as dressings over
a qualifying wound.
The record does not show that the enrollee has open venous stasis ulcers or a qualifying wound. This means that the enrollee does not have a medical condition for which compression stockings can be covered or paid for
by Medicare. Therefore, we decided that the Plan does not have to pay for the compression stockings identified
with code A6530 that were issued on March 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation treatment provided on November 5, 2019.
You asked the Plan to waive the copayment for radiation treatment. You say that the cost is a lot. You say that you want help with the copayment. 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 a $60 copayment for each Medicare-covered, in-network, radiation (radium and isotope) therapy service. You have been asked to pay a $60 copayment for the radiation treatment. The radiation treatment 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 radiation treatment provided on November 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to approve additional payment for the hearing aids provided on January 11, 2019.
You asked the Plan to approve for the hearing aids. You say that that hearing aids are covered by the Plan. The Plan denied your request. The Plan says that you have exceeded limits set in the subscriber agreement.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan covers up to a $4,800 allowance for hearing aids every three years. We looked at the file and the Plan's rules. The file shows that the plan has approved the maximum 3-year benefit of $4,800 for the requested services. There is no provision in the contract which would require the plan to approve more than this amount. Therefore, we decided that the Plan does not have to approve additional payment for the hearing aids provided on January 11, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for extracapsular cataract removal provided at
an ambulatory surgical center on November 11, 2019.
You asked the Plan to waive the copayment for extracapsular cataract removal. You say that you cannot afford
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 $225
copayment for outpatient surgery services provided in an ambulatory surgical center.
You have been asked to pay a $225 copayment for extracapsular cataract removal. Extracapsular cataract
removal falls 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 copayment for
extracapsular cataract removal provided at an ambulatory surgical center on November 11, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve four additional physical therapy visits. You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says only eight visits are reasonable. The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy of 4 more visits is generally not accepted as specific and effective therapy for your condition. Your deficits are not so complex that you would require additional therapy beyond what the health plan approved. You can be trained in a home exercise program with the already authorized therapy. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program, and the specialized skill, knowledge and judgment of a qualified therapist is not required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. 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 visits have not been met. Therefore, we decided that the Plan does not have to pre-approve four additional physical therapy visits.