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

We decided that the Plan does not have to pay for laboratory services provided on January 3, 2020.You asked the Plan to pay for the laboratory services. You say that the original authorization for the enrollee's services had been obtained by the treating facility and the enrollee had no control over where the pathologist or physician had referred these 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 and the referring provider in this case are not network providers with the Plan. The Plan did not pre-approve the laboratory services.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 laboratory services provided on January 3, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 7-month home ventilator rental (E0466).
You asked the Plan to pre-approve the home ventilator rental. You say that you would like reconsideration as this service is medically necessary for the treatment of your consideration. The Plan denied your request. The Plan says a 12 month rental authorization cannot be approved without recent labs.
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 home ventilator rental. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record shows that you have COPD, but do not retain CO2 and do not meet criteria for home oxygen. 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 home ventilator rental have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 7-month home ventilator rental (E0466).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for extracapsular cataract removal provided at an outpatient hospital facility on September 5, 2019 and September 18, 2019.
You asked the Plan to waive the copayments for extracapsular cataract removal. You say that you should only owe a $200 copayment because the services were provided in an ambulatory surgical center. 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 65 Basic Rx members must pay a $350 copayment for outpatient hospital facility services. You received extracapsular cataract removal on September 5, 2019 and September 18, 2019 at an outpatient hospital facility. Therefore, you are responsible to pay a $350 copayment per each visit. The total amount you owe is $700. You have been asked to pay the total copayment amount of $700 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 copayments for extracapsular cataract removal provided at an outpatient hospital facility on September 5, 2019 and September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for orthotic management and training (97760) provided on November 7, 2019 through December 6, 2019.You asked the Plan to pay for the orthotic management and training. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the record does not support the service billed.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 97760 is orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes.We find that CPT code 97760 is not supported in the record. Specifically, the documentation submitted does not indicate the time spent providing the service billed. Based on this information, we decided that Medicare rules for coverage of the orthotic management and training have not been met.Therefore, we decided that the Plan does not have to pay fororthotic management and training (97760) provided on November 7, 2019 through December 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on June 17, 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 the services are not separately payable.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay for the special pump services rendered on June 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on February 3, 2020.You asked the Plan to pay for the 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 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 for the medical services provided to the enrollee by an out-of-network provider on February 3, 2020.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the arch supports provided on September 4, 2019.
You asked the Plan to pay for the arch supports. You say that the podiatrist that provided the arch supports is contracted. The Plan denied your request. The Plan says that the record shows you do not have diabetic foot disease and the Evidence of Coverage is clear that the items are therefore not covered.
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Health Plan follows these rules. You were referred for the arch supports by your physician. That physician is a contract provider. The file does not show that Health Plan provided notice that the arch supports would not be covered. The EOC was not adequate notice of non-coverage of arch supports and the contracted provider did not advise you the arch supports may not be covered. Under Medicare rules, this means the arch supports are considered approved by the Health Plan. Therefore, we decided that the Plan has to pay for the arch supports provided on September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on September 18, 2019.You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the submitted documentation is missing required information.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 the laboratory services are not supported in the medical record. Specifically, the submitted documentation did not contain a physician order or laboratory results from the billing provider. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 18, 2019.
Appeal type: ER
Decision: Unfavorable

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that providers must report services correctly. Procedures should be reported with the CPT code that describes the services performed. You can find this rule in the Medicare National Correct Coding Initiative Manual, Chapter I(A).
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan says it covers emergency/urgent care visits outside the United States and its territories as a supplemental benefit. Services are covered through reimbursement in accordance to Triple-S Advantage, Inc. rates. There is a maximum coverage limit up to $75.00 for incurred costs for emergency/urgent care services. You can see this on page 67 of the 2019 Evidence of Coverage.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the observation stay provided from January 6, 2020 to January 7, 2020.
You asked the Plan to waive the copayment for the observation stay. You say that you do not believe you should be responsible for the copayment. 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 $350 copayment per date of service at an outpatient hospital facility. You have been asked to pay a $350 copayment for the observation stay. The observation stay falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The medical record shows you were admitted into observation.
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 observation stay provided from January 6, 2020 to January 7, 2020.
Your complaint about the poor treatment is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from December 4, 2019 to December 20, 2019.
You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says payment is not allowed for this service because it is not billed with a valid type of bill code.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim includes an invalid type of bill code for home health services. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from December 4, 2019 to December 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 29, 2019 by an out of network (OON) provider.You asked the Plan to pay for the polysomnography. You say that you would like reconsideration because you were given incorrect insurance information from the member.The Plan denied your request. The Plan says this service was rendered out-of-network without 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 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 October 29, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided from May 30, 2019 to July 11, 2019.You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says there is no valid referral for this service.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 chiropractic services. 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 chiropractic services provided from May 30, 2019 to July 11, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 7, 2019.You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 the laboratory services are not supported in the medical record. Specifically, there is no evidence of an established relationship between the enrollee and the ordering physician. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met.Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 7, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan injections.You asked the Plan to pre-approve the Rituxan. You say that this would be the best drug to treat the enrollee's condition.The Plan denied your request. The Plan says there has not been a trial of the plan's preferred drugs in order to support the need for Rituxan.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 the Rituxan. Our reviewer says that the requested medication is not considered medically reasonable and necessary based on step therapy criteria. Our physician reviewer found the enrollee has a diagnosis of Rheumatoid arthritiswith rheumatoid factor of multiple sites without organ or systems involvement. The case file does not contain documentation of trial and failure of Inflectra or Remicade and Simponi Aria. There is also no documentation that these drugs would likely be lesseffective, and/or would likely have adverse effects for the enrollee in this case.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 Rituxan have not been met.Therefore, we decided that the Plan does not have to pre-approve Rituxan injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the SNF services provided from August 1, 2019 to August 19, 2019.
You asked the Plan to pay for the SNF services. You say that you did not know you needed to get prior authorization for the SNF services. The Plan denied your request. The Plan says if you do not have prior authorization or your request is denied for services from out-of-network providers, the services will be processed by Original Medicare.
The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. The services at issue in this appeal were not provided in an emergency or urgent care situation. These services were not provided by the Plan or through arrangements with them. Therefore, we decided that the Plan does not have to pay for SNF services provided from August 1, 2019 to August 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on December 2, 2019 by an out of network (OON) provider.You asked the Plan to pay for chiropractic services. You say that you did not know that the member had changed her insurance plan. You say that you did not know that prior authorization was required.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 chiropractic services provided on December 2, 2019 by an out of network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve allowance for health food purchases and/or electricity, water and/or phone bill payments.
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says you have none of the qualifying diagnoses, you do not require intense care coordination and you have no high risk for hospitalizations or high risk for adverse health outcomes.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. You do not meet the criteria established to receive the debit card for allowance for health food purchases and/or electricity, water and/or phone bill payments for 2020. Therefore, we decided that the Plan does not have to pre-approve allowance for health food purchases and/or electricity, water and/or phone bill payments.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion or replacement of permanent leadless pacemaker (33274) provided on September 4, 2019.You asked the Plan to pay for the insertion or replacement of permanent leadless pacemaker. You say that this should be paid.The Plan denied your request. The Plan says the enrollee is not in an approved clinical trial.The Plan must follow Medicare rules. Medicare rules say that the Centers for Medicare & Medicaid Services (CMS) covers leadless pacemakers through Coverage with Evidence Development (CED). CMS covers leadless pacemakers when procedures are performed in Food and Drug Administration (FDA) approved studies. CMS also covers, in prospective longitudinal studies, leadless pacemakers that are used in accordance with the FDA approved label for devices that have either an associated ongoing FDA approved post-approval study or completed an FDA post-approval study.We looked at the file and Medicare rules. The record does not indicate that this service was provided in connection with an approved clinical study. Based on this information, we decided that Medicare rules for coverage of the insertion or replacement of permanent leadless pacemaker have not been met.Therefore, we decided that the Plan does not have to pay for the insertion or replacement of permanent leadless pacemaker (33274) provided on September 4, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next brand diabetic test strips.
You asked the Plan to pre-approve the Contour brand test strips. You say that the test strips are medically necessary. The Plan denied your request. The Plan says the plan only covers Lifescan brand diabetic test strips and meters.
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands. We looked at the file and Medicare rules. The requested Contour Next test strips are not a brand the plan covers. No medical records were provided to show any reason why the plan preferred products would not be medically appropriate for this enrollee. Based on this information, we decided that Medicare rules for coverage of the Contour brand test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Next brand diabetic test strips.