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

We decided that the Plan does not have to pay for oxygenator assembly and operation services provided to the
enrollee on June 5, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says any and all codes on this claim are denied, and in addition, previous payments to these providers
for this member are subject to recoupment
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 denied codes are not supported in the medical record. Specifically, the payment for the denied
codes is included in the payment for the facility. 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 for
oxygenator assembly and operation services provided to the enrollee on June 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve butalbital/acetaminophen/caffeine.
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that drug coverage is limited to Medicare Part B covered drugs.
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 butalbital/acetaminophen/caffeine.
Benefits for this drug 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a spinal bone growth stimulator (BGS).
You asked the Plan to pre-approve the spinal BGS. You say that the enrollee would benefit from this BGS to provide the best chance of a successful lumbar fusion. The Plan denied your request. The Plan says the Medicare criteria for the BGS are not met.
The Plan must follow Medicare rules. Medicare rules say that spinal BGS is covered when enrollees have failed spinal fusion after at least nine months have passed since surgery, when enrollees have received a multilevel spinal fusion, or for those with a history of failed fusion of the spine. In this case, the spinal fusion procedure was less than four months ago and involved only a single spinal level, L4-L5. There is no documentation of a history of a prior failed fusion. As such, we find that the Medicare criteria for the BGS have not been met. Therefore, we decided that the Plan does not have to pre-approve a spinal bone growth stimulator (BGS).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve repeat radiofrequency ablation (RFA) for the enrollee.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. 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 RFA is covered when specific criteria are met.
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 these services. Our reviewer says that
the services are medically necessary. Our physician reviewer found the enrollee has chronic back pain and had
prior RFA of the medial branches with success. It is not necessary to repeat the diagnostic medical branch
block injections. It is medically necessary to repeat the RFAs, since the pain relief lasted more than six months
with the prior treatment. This is a separate issue from her radicular issues.
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 preapprove
repeat radiofrequency ablation (RFA) for the enrollee.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on June 25, 2019.
You asked the Plan to waive the copayment for the office visit. You say that this was your annual physical exam and there should be no charge. 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 $10 copayment for in-network primary care physician office visits. You have been asked to pay a $10 copayment for the office visit. The office visit falls within the "Physician/
Practitioner services, including doctor's office visits" benefit category. The record shows you were seen for non-preventive services.
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 office visit provided on June 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement folding walker with seat.
You asked the Plan to pre-approve a replacement folding walker with seat. You say that you think you may be injured if your rollator is not repaired correctly. The Plan denied your request. The Plan says you received a rollator in March 2017 and you have been approved for repairs to the rollator.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. Your current walker is still under reasonable useful lifetime. The file shows that you have been approved for walker repairs. Therefore, we decided that the Plan does not have to pre-approve a replacement folding walker with seat.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the foot orthotics (L3000).
You asked the Plan to pre-approve foot orthotics (L3000). You say that the custom orthotic will greatly help with all of your conditions and possibly prevent additional conditions from starting. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of foot inserts for your condition. Therefore, we decided that the Plan does not have to pre-approve the foot orthotics (L3000).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. 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 and the documentation does not support he can tolerate 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that the services are necessary. 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 your 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 you require the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but you do 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services provided on August 9, 2019.You asked the Plan to pay for the pathology services. Yousay that you are a laboratory and rely on the referring physician to provide the necessary information in order for the claims to be processed. The Plan denied your request. The Plan says the service was received from an out-of-network provider and the enrollee does not have out-of-network 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 providerand the ordering provider in this case are notnetwork providerswith the Plan. The Plan did not pre-approve the servicesat 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 pathology services providedon August 9, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an extremity study (93971) provided on June 22, 2019.You asked the Plan to pay for the extremity study. You say that you are not allowed to bill globally per CMS. The Plan denied your request. The Plan says the providers that rendered the professional and technical components of this service have the same TIN. This code should be billed globally.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We find that CPT code 93971 is not supported in the record. Specifically, the provider rendered both the professional and technical component of this service. This means that 93971 should be billed globally and not with modifiers TC and 26 on the same line. Based on this information, we decided that Medicare rules for coverage of the extremity study. have not been met. Therefore, we decided that the Plan does not have to pay for an extremity study (93971) provided on June 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea coronary computed tomography (CT) scan for quantitative calcium scoring.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that quantitative calcium scoring is not a covered service and will be denied as not medically necessary. The services at issue are a coronary CT scan for quantitative calcium scoring. These services are denied as not medically necessary.Therefore, we decided that the Plan does not have to pre-approvea coronary computed tomography (CT) scan for quantitative calcium scoring.
Appeal type: Home Health
Decision: Favorable

We decided that the Plan has to pay for home health care services provided on July 24, 2019.You asked the Plan to pay forhome health care services. You say that this service was authorized.The Plan denied your request. The Plan says that the service billed is different thanthe service that was prior authorized.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. Specifically, although the Plan states that the service billed is different than the service that was prior authorized, no documentation was provided to substantiate that reasoning.The record did not contain a claim form to show how services were billed. The Explanation of Benefits within the record did not contain information to show how services were billed. Without the claim form showing how services were billed, the Plan denial cannot be substantiated and we must find in your favor.Therefore, we decided that the Plan has to pay forhome health care services provided on July 24, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not haveto pay forthe ophthalmology services provided on May 7, 2019 by out of network provider.You asked the Planto pay forthe OON services. You say that the physician is a network provider with the plan as he was paid for a different patient on the same EOB.The Plandenied your request. The Plansaysthough the provider is in-network with certain plans, he is an out of network provider with this enrollee's particular plan.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services atissue 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 Plandoes not haveto pay forthe ophthalmology services provided on May 7, 2019 by out of network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe specialist office visit provided on April 24, 2019.You asked the Plan to waive the copayment forthe specialist office visit. You say that you will not pay this bill. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must discloseto 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 a specialist visit. The Plan also says a $5.00 credit was applied towards this visit and you owe a $45 copayment. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "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 forthe specialist office visit provided on April 24, 2019.Your complaint about the poor medical service 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe diagnostic mammogram and ultrasounds provided on September 16, 2019.You asked the Plan to waive the coinsurance forthe diagnostic mammogram and ultrasounds. You say that the bill should be processed in-network.The Plan denied your request. The Plan says the coinsurance 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 40% coinsurance for diagnostic mammography at an out-of-network provider and 40% coinsurance for diagnostic procedures and tests at an out-of-network provider.You have been asked to pay a total of $47.38 for the diagnostic mammogram and ultrasoundsThe diagnostic mammogram and ultrasounds fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the provider is out-of-network. 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 coinsurance forthe diagnostic mammogram and ultrasounds provided on September 16, 2019
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out-of-network provider.You asked the Plan to pre-approvethe services. The Plan denied your request. The Plan says the services are not urgent or emergent.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 pre-approved care.The requested provider in this case is not a networkprovider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by an out-of-network provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel for the enrollee.You asked the Plan to pre-approveEnbrel. You say that the enrollee's pain anddeterioration of joints has slowed down since taking Enbrel.The Plan denied your request. The Plan says that this is not covered under the member's plan under any normal circumstances.The Plan must follow Medicare rules. The rules say that MedicarePart 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-approveEnbrel for the enrollee.Benefits for Enbrelmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repathata sureclick.You asked the Plan to pre-approvethis drug. You say that this is medically necessary.The Plan denied your request. The Plan says that drug coverage for is limited to Medicare Part B covered drugs only.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-approveRepathata sureclick.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on June 14, 2019.You asked the Plan to reimburse you forthe dental services. You say that the closest in network dentist is 30 minutes from your house. You say that theyare not reputable. You also say that you do not feel comfortable going there. The Plan denied your request. The Plan says the provider in this case is not a network provider with the Plan. The Plan also says that services received from an out of network provider are not covered.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 benefitin excess of Medicare coverage and the services you received are listed as covered, the services are not covered when they are received out of network.Therefore, we decided that the Plan does not have to reimburse you forthe periodic oral evaluation(D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on June 14, 2019