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

We decided that the Plan does not have to pay for diagnostic radiology services provided on July 26, 2019.You asked the Plan to pay for the diagnostic radiology 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 Plandid 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 diagnostic radiology services provided on July 26, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the polysomnography services represented by CPT code 95810.You asked the Plan to pre-approve the polysomnography services represented by CPT code 95810. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested 95810 duplicates the diagnostic portion of the approved split night study and is inclusive in the services provided by the approved 95811 code.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 95810 is Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, attended by a technologist.We find that CPT code 95810 is not supported in the medical record. Specifically, the Plan has approved coverage of CPT code 95811, which is defined by the CPT Code Manual as Polysomnography; age 6 years or older, sleep staging with 4 or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bi-level ventilation, attended by a technologist. This approved CPT code includes the services represented in CPT code 95810. Based on this information, we decided that Medicare rules for coverage of the polysomnography services represented by CPT code 95810 have not been met.Therefore, we decided that the Plan does not have to pre-approve the polysomnography services represented by CPT code 95810.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay foroffice visit services provided to the enrollee on June 19, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysprior authorization for these services was not obtained.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, outof 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 Plandoes not haveto pay foroffice visit services provided to the enrollee on June 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (CPT E2377), a harness (CPT E2313), an electronic connection (CPT E2311), and a power seat elevation feature (CPT E2300).
You asked the Plan to pre-approve the power seat elevation feature and the upgraded electronics. You say that the enrollee has Muscular Dystrophy and Cerebral Palsy. The appellant says that the enrollee is non-ambulatory and has deformities and involuntary muscle spasms commonly associated with these diagnoses. The appellant says that this requires a multiple power chair device with power seating functions. The appellant says that the enrollee is a very high fall risk. The Plan denied your request. The Plan says a power seat elevation feature is not covered by Medicare. The Plan says that the updated electronics are not medically necessary. The Plan says that the enrollee has no medical need to control power options through a joystick rather than using his own switches.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Medicare rules also say that power seat elevation features (CPT E2300) are non-covered because they are not primarily medical in nature. 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 power seat elevation feature and the upgraded electronics. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's strength and ability to feed himself should be sufficient to be able to control the power options using his own separate switches. 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 power seat elevation feature and the upgraded electronics have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (CPT E2377), a harness (CPT E2313), an electronic connection (CPT E2311), and a power seat elevation feature (CPT E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the add tooth to existing partial denture, mandibular partial denture, and resin-based composite provided on August 8, 2019 and August 15, 2019.
You asked the Plan to pay for the add tooth to existing partial denture and mandibular partial denture. You say that the enrollee has not had a lower denture made and needs one because she has to have 3 teeth removed. You also say that the enrollee cannot eat properly without the lower partial denture. The Plan denied your request. The Plan says the add tooth to existing partial denture service is not covered. The Plan also says that the benefits for the mandibular partial denture have been satisfied and the frequency limitation has been exceeded.
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 add tooth to existing partial denture is not among those covered under this benefit. The contract also clearly says that partial dentures are limited to one upper and/or one lower partial denture every five years. The record shows that you received a mandibular partial denture on May 9, 2019 and your partial denture benefit is now exhausted. Therefore, we decided that the Plan does not have to pay for the add tooth to existing partial denture, mandibular partial denture, and resin-based composite provided on August 8, 2019 and August 15, 2019.
Your complaint about the previous provider's lack of care and taking advantage of the enrollee's situation 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: Imaging
Decision: Favorable

We decided that the Plan has to reduce the cost share for the emergency room visit provided from October 1, 2019 to October 3, 2019.You asked the Plan to reduce the cost share forthe emergency room visit. You say that you should went to the emergency room and were admitted. You say you should only be responsible for the copayment. The Plan denied your request. The Plan says that you have been charged the correct cost sharing amount.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 coverageor 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 did not submit medical records to support that these services were not provided as an emergency room stay. Therefore, the plan has not shown that the cost share amounts you are being asked to pay is correct or justified by the health plan contract. Therefore, we decided that the Plan has to reduce the cost share forthe emergency room visit provided from October 1, 2019 to October 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug provided on October 1, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug. You say that you were told that you would only owe a $225 copayment. 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 20% coinsurance for Medicare Part B prescription drugs.
You received a Medicare Part B drug on October 1, 2019. The allowed amount is $4,245.30 and 20% of that is
$849.06.
You have been asked to pay the total coinsurance amount of $849.06 for a Medicare Part B drug. A Medicare Part B drug falls within the Medicare Part B prescription drugs 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 coinsurance for a Medicare Part B drug provided on October 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Entresto tablets.You asked the Plan to pre-approve self-administered drugs. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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 Entresto tablets.Benefits for self-administered drugsmay 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 pay for the knee orthosis with suspension sleeve rendered to the enrollee on September 16, 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 payable.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the knee orthosis with suspension sleeve rendered to the enrollee on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing (80307, G0480) provided on August 2, 2019 by out of network provider.You asked the Plan to pay for drug testing. You say that you are appealing the claim payment denial for services rendered to the member on date of service August 2, 2019. You disagree with the decision made where the claim denied due to missing prior authorization and you are requesting reconsideration on this claim. You were not aware of the requirement of obtaining a prior authorization.The Plan denied your request. The Plan says the rendering provider  is a non-participating provider. The plan did not authorize any services. The services are not considered urgent/emergent in nature. There are multiple in-network providers within 30 miles of the member's residence that could have rendered the 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 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 drug testing (80307, G0480) provided on August 2, 2019 by out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transcathetermitral valve repair (TMVR) and hospital inpatient admission.You asked the Plan to pre-approve a transcatheter mitral valve repair (TMVR) and hospital inpatient admission. You say that the requested TMVR is medically necessary.The Plan denied your request. The Plan says the MitraClip is currently the only US FDA approved device for transcatheter mitral valve repair and the medical record does not document that the enrollee is part of an FDA-approved randomized controlled trial.The Plan must follow Medicare rules. Medicare rules say that transcatheter mitral valve repair (TMVR) is covered when furnished under Coverage with Evidence Development (CED) for the treatment of mitral regurgitation (MR) and the TMVR system has received FDA premarket approval for that systems FDA-approved indication. The rules say that TMVR is not covered for the treatment of MR when not furnished under CED. In this case, the record shows that a SAPIEN TAVR valve is not FDA-approved for transcatheter mitral valve repair and is not listed in the CED registry for TMVR.Therefore, we decided that the Plan does not have to pre-approve a transcatheter mitral valve repair (TMVR) and hospital inpatient admission.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the Part B injection provided on September 9, 2019.
You asked the Plan to reduce the coinsurance for the Part B injection. You say that you have always paid a $40 copayment and you have been getting these shots for over three years. 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 20% coinsurance for Medicare-covered Part B chemotherapy prescription drugs. You have been asked to pay $382.94 which is 20% of the allowed amount for the Part B injection. The allowed amount is $1,914.72. ($1,914.72 x 20% = $382.94). The Part B injection falls within the "Medicare Part B prescription drugs" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to reduce the coinsurance for the Part B injection provided on September 9, 2019.
Our decision is only about the 2019 services. If you have any questions about prior years billing, please contact the plan directly.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy (90837) provided on June 11, 2018.You asked the Plan to pay for the psychotherapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was submitted after the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the psychotherapy was not filed until July 11, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for psychotherapy (90837) provided on June 11, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemethylprednisolone acetate.You asked the Plan to pre-approvethese services. You say that the services are medically necessary.The Plan denied your request. The Plan says 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 not medically necessary. Our physician reviewer found the submitted records show that you have a diagnosis of tennis elbow (lateral epicondylitis) of the left elbow. Methylprednisone acetate is not FDA-approved for the treatment of this diagnosis. Studies have shown that patients who receive treatment with this drug for this condition may have worse outcomes inthe long term. Methylprednisone acetate is therefore not considered safe and effective and reasonable or medically necessary at this time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pre-approvemethylprednisolone acetate.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-one 48mg/6ml solution (J7325).
You asked the Plan to pre-approve this medication. You say that this medication is medically necessary as the
patient has Osteoarthritis of the knees. The Plan denied your request. The Plan says this drug is subject to a step
therapy requirement. They may consider approval of this product when one preferred product is tried first
(when there was a trial and inadequate response or intolerance to one preferred product, which includes
Euflexxa, Supartz/FX, Durolane, and Gelsyn-3. The Plan did not see information that shows the member had a
poor response or did not tolerate one preferred product first or cannot use it for medical reasons (a
contraindication such as a known hypersensitivity to any ingredient in the preferred agents.
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 this medication. Our reviewer says that
the patient does not meet criteria for coverage of Synvisc-one. Our physician reviewer found the patient has not
tried and failed the required drugs. The documentation does not support that Euflexxa, Supartz/FX, Durolane,
and Gelsyn-3 would likely be less effective, 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 this medication have not been met. Therefore, we decided that the Plan does not
have to pre-approve Synvisc-one 48mg/6ml solution (J7325).
Appeal type: Surgery
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 a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR 422.111(a) and (b). The rules say that a copayment is a fixed amount charged to an enrollee on a per-service basis. The rules say that coinsurance is a fixed percentage of the total amount paid for a health care service that can be charged to an enrollee on a per-service basis. You can find this rule at 42 CFR 422.2.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The Plan contract says that enrollees must pay a $50 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You can find this information in Chapter 4 on pages 83 - 84 of the Plan's 2019 Evidence of Coverage.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa Cap 1gm.You asked the Plan to pre-approve Vascepa Cap 1gm. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit, therefore self-administered drugs do not meet the criteria for coverage.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 Vascepa Cap 1gm.Benefits for Vascepa Cap1gmmay 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea referral to an out-of-network provider.You asked the Plan to pre-approvethe referral. You say that this is medically necessary.The Plan denied your request. The Plan says this facility is not in the network.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 network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea referral to an out-of-network provider.