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

We decided that the Plan does not have to pre-approve Repatha 140mg/ml Sureclick. You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the request cannot be approved, because the enrollee has a medical only policy. 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 Repatha 140mg/ml Sureclick.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee scooter (W0118) purchased September 3, 2019. You asked the Plan to pay for the knee scooter. You say that this item was medically necessary and your only option. You were not able to use crutches or a walker due to having only 1 uninjured limb and your house is not wheelchair accessible. The Plan denied your request. The Plan says this provider is not a Medicare approved durable medical equipment provider. This item is not covered.
The Plan must follow Medicare rules. Medicare rules say that a provider must be enrolled in the Medicare program in order to receive payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee scooter have not been met. Therefore, we decided that the Plan does not have to pay for the knee scooter (W0118) purchased September 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for negative pressure wound therapy electrical pump, stationary or portable (E2402) provided on June 25, 2019 by an out-of-network provider. You asked the Plan to waive the coinsurance for the DME. You say that no one gave you the choice of in-network versus out-of-network companies and their products. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file show that you received DME provided on June 25, 2019 by an out-of-network provider. You are asked to pay 20% coinsurance for the DME. Your EOC states, provided on June 25, 2019 by an out-of-network provider. Therefore, you would be paying 20% coinsurance for the DME if you had used an in-network provider. 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 for negative pressure wound therapy electrical pump, stationary or portable (E2402) provided on June 25, 2019 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nerve conduction studies (95909) and needle electromyography (95885) provided on September 13, 2019. You asked the Plan to pay for nerve conduction studies and needle electromyography. You say that this should be reconsidered. The Plan denied your request. The Plan says these codes are not shown in the medical records. 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 95909 is nerve conduction studies; 5-6 studies and 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for nerve conduction studies and needle electromyography. Our reviewer says that these codes are not supported. Our physician reviewer found the enrollee received intraoperative neuromonitoring. There is no evidence that the enrollee underwent neurologic testing; specifically, nerve conduction studies. As such, the billing of CPT 95909 for nerve conduction studies and CPT 95885, which must occur in the presence of nerve conduction studies, is not supported. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nerve conduction studies and needle electromyography have not been met. Therefore, we decided that the Plan does not have to pay for nerve conduction studies (95909) and needle electromyography (95885) provided on September 13, 2019.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve paclitaxel protein bound, carboplatin, palonosetron, and dexamethasone. You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary. The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the services are medically necessary. Our physician reviewer found the enrollee has recurrent endometrial cancer and was started on carboplatin and paclitaxel but developed hyperglycemia from steroids. Paclitaxel protein bound does not require steroids and is a standard substitution when patients cannot tolerate steroids needed for paclitaxel. Lower doses are needed with protein bound paclitaxel. The combination of carboplatin, protein bound paclitaxel and supportive medications: palonsetron and dexamethasone is reasonable and medically necessary for this enrollee. It is safe and effective. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pre-approve paclitaxel protein bound, carboplatin, palonosetron, and dexamethasone. 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 pay for an office visit provided on November 5, 2019 by an out of network (OON) provider. You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member resides in a long term care unit of nursing facility and was not under inpatient skilled care at the time of 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 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 an office visit provided on November 5, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed with mattress (E0260, E0271). You asked the Plan to pre-approve the semi-electric hospital bed with mattress. You say that the bed is medically necessary. The Plan denied your request. The Plan says rules for coverage have not been met. The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 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 semi-electric hospital bed with mattress. Our reviewer says that the requested bed is not medically necessary. Our physician reviewer found while it is reported that the enrollee needs a semi-electric bed due to GERD, there is no objective documentation that the enrollee is unable to eat out of bed or is unable to reposition herself in bed. Furthermore, there is no objective documentation that the enrollee needs rapid and frequent re-positioning while in bed. 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 semi-electric hospital bed with mattress have not been met. Therefore, we decided that the Plan does not have to pre-approve a semi-electric hospital bed with mattress (E0260, E0271).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Buprenorphine 20 mcg/hr patch. You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription 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 Buprenorphine 20 mcg/hr
patch.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the chiropractic services you received from October 1, 2019, to November 25, 2019. You asked the Plan to pay for the services. You say that the services were necessary. The Plan denied your request. The Plan says that the services were billed incorrectly. 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 indicates that the services were billed incorrectly, but does not provide documentation showing a billing error. The records do not show any indication of a billing error. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the chiropractic services you received from October 1, 2019, to November 25, 2019. If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Alrex 0.2% eye drops for the enrollee. You asked the Plan to pre-approve the drops. You say that this is medically necessary. The Plan denied your request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription 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 Alrex 0.2% eye drops for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair. You asked the Plan to pre-approve the requested chair. You say that a group 3 chair would allow the enrollee to be mobile in all living environments. The Plan denied your request. The Plan says the documentation does not show the enrollee cannot safely use a cane, walker, manual wheelchair, or scooter. The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for certain medical indications. 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 for a group 3 wheelchair. Our physician says that the enrollee has hemiplegia with mobility deficits from a traumatic brain injury. It is not clear that it impairs participation in mobility-related activities of daily living, as he is independent with dressing, eating, toileting in the home. The seating mobility evaluation states that this wheelchair is to be used for outside of the home. Furthermore, the documentation reveals the enrollee can use a wheeled walker. There is no evidence of failure of a trial of a manual wheelchair. Therefore, the requested wheelchair is not medically reasonable or necessary. We looked at this physician's review, the file, and the rules. Based on this information, we decided that the Medicare rules for coverage of a group 3 power wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the three additional intraoral periapical x-rays and oral hygiene instructions provided on January 29, 2020. You asked the Plan to pay for the three additional intraoral periapical x-rays and oral hygiene instructions. You say that at your appointment you were told that the dentist you would be seeing was in network with your plan. The Plan denied your request. The Plan says these services are not covered benefits Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the three additional intraoral periapical x-rays and oral hygiene instructions provided on January 29, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nuedexta 20-10mg capsules. You asked the Plan to pre-approve the capsules. You say that this is medically necessary. The Plan denied your request. The Plan says the medication falls under Part D coverage, but the enrollee does not have a Part D pharmacy 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 Nuedexta 20-10mg capsules.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit provided on March 11, 2020. You asked the Plan to pay for the full mouth debridement. You say that the contract does not state what type of cleanings are covered. You also say that you feel that you went through all of the proper channels to get preventive dental care as it is stated in your policy. The Plan denied your request. The Plan says this service is not a covered benefit under your plan. Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit is a periodontic service. The Plan contract says that 2 cleanings are covered each year, however, the contract also states that periodontic services are excluded from coverage. Therefore, we decided that the Plan does not have to pay for the full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit provided on March 11, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on January 8, 2018. You asked the Plan to waive the copayment for the ER visit. You say that you pay $0 for emergency room visits. 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 $75 per visit for emergency care. You have been asked to pay a $75 copayment for the ER visit. The ER 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 the ER visit provided on January 8, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee on January 2, 2020. 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 there is a deductible that has not been met yet. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1000 deductible for covered medical services. The item or service you asked the Plan to pay for falls within the benefit category covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time the services was received on January 2, 2020. Therefore, we decided that the Plan does not have to pay for outpatient hospital services provided to the enrollee on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for face-to-face behavioral counseling services (HCPCS G0447) provided to the enrollee on November 7, 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 an appropriate modifier to represent the services as separate and distinct was not used. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. In this case, the CPT Code Manual definition of HCPCS code G0447 is "face-to-face behavioral counseling for obesity, 15 minutes." We find that HCPCS code G0447 is not supported in the medical record. Specifically, this code is a column II procedure to the column I procedure - CPT 99214 - already billed in this case. 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 face-to-face behavioral counseling services (HCPCS G0447) provided to the enrollee on November 7, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ALS specialized service disposable supplies, IV drug therapy (A0394) ALS routine disposable supplies (A0398) provided December 27, 2019. You asked the Plan to pay for the ambulance services. You say that you are asking for an appeal. Due to extreme anemia you could not drive yourself to the hospital which is 10 miles from your house. The Plan denied your request. The Plan says payment for these items is included in the transportation fee. The Plan must follow Medicare rules. Medicare rules say that Medicare does not allow for separate billing of these services and supplies as payment for these items is included in the transportation fee. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Therefore, we decided that the Plan does not have to pay for ALS specialized service disposable supplies, IV drug therapy (A0394) ALS routine disposable supplies (A0398) provided December 27, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the outpatient clinic visits provided on February 15, 2020 and February 29, 2020. You asked the Plan to waive the copayments for the outpatient clinic visits. You say that you saw your primary care physician and should have a $0 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 $425 copayment for Medicare-covered outpatient hospital services. You have been asked to pay a $45 copayment for each of the outpatient clinic visits, which is less than the standard copayment amounts. The outpatient clinic visits fall within the "Outpatient hospital services" benefit category. The record shows you were billed by the outpatient hospital facility. 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 the outpatient clinic visits provided on February 15, 2020 and February 29, 2020.