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

We decided that the Plan does not have to pay forthe medical services provided on August 6, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe medical services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 andpre-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 forthe medical services provided on August 6, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tocilizumab injections (Actemra).
You asked the Plan to pre-approve the Tocilizumab injections (Actemra). The Plan denied your request. The
Plan says the information submitted does not meet the Plan's medical necessity guidelines for coverage.
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 Tocilizumab injections (Actemra).
Our reviewer says that the criteria coverage has not been met. Our physician reviewer found the enrollee has
not tried and failed the required drugs, Remicade or Inflectra and Spimponi Aria. Our reviewer found that the
documentation does not support that Remicade or Inflectra, and Spimponi Aria would likely be less effective,
and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer also found that
the enrollee has not had prior therapy, contraindication, or intolerance with Remicade or Inflectra and
Spimponi Aria.
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 Tocilizumab injections (Actemra). have not been met. Therefore, we
decided that the Plan does not have to pre-approve Tocilizumab injections (Actemra).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for non-emergency transportation trips (A0100) provided on November 12, 2019 by the provider.
You asked the Plan to waive the copayment for the non-emergency transportation trips. You say that you should not be responsible for the copayment since you were not told there would be an additional charge for stopping at the pharmacy. The Plan denied your request. The Plan says based on Medicare billing criteria, the claim was billed correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 copayment for each one-way transportation trip. You have been asked to pay $30 for the non-emergency transportation trips. 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 non-emergency transportation trips (A0100) provided on November 12, 2019 by the provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection services rendered on December 11, 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 procedure code J3301 is not supported. 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 J3301 is injection, triamcinolone acetonide, not otherwise specified, 10 mg. We find that CPT code J3301 is not supported in the medical record. Specifically, the documentation does not support the units billed. 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 pay for the injection services rendered on December 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the interim partial denture provided on December 5, 2019.
You asked the Plan to pay for the interim partial denture. The Plan denied your request. The Plan says that this
is not covered by 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. Therefore, we decided that the Plan does not have to pay for the
interim partial denture provided on December 5, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe myocardial perfusion imaging and regadenoson injection provided on January 2, 2020.You asked the Plan to waive the cost share forthe myocardial perfusion imaging and regadenoson injection. You say that you have never been charged this much for these services before. You say that this is an overcharge.The Plan denied your request. The Plan says the cost share applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for each in-network, Medicare-covered diagnostic imaging service and20% coinsurance for each Medicare-covered Part B drug from an in-network provider. You have been asked to pay a total of $172.38 for the myocardial perfusion imaging and regadenoson injection. The myocardial perfusion imaging falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The regadenoson 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 waive the cost share forthe myocardial perfusion imaging and regadenoson injection provided on January 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dental surgical procedures received from May 13, 2015 to
December 13, 2016.
You asked the Plan to pay for the dental services. You say that this should be paid for. The Plan denied your
request. The Plan says this is not a covered benefit.
Medicare generally does not cover dental services. The Plan follows the same rule.
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental surgical procedures
received from May 13, 2015 to December 13, 2016.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe power mobility device and sales tax provided to the enrollee on July 13, 2019.You asked the Plan to pay forthese services. You say that the enrollee was told this would be paid for.The Plan denied your request. The Plan says that the information received is insufficient for claim processing.The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capableof safely operating the requested PMD. 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 these services. Our reviewer says that these services were not medically reasonable and necessary for the enrollee in this case. This patient has a personal mobility deficit but it is not clear that it impairs participation in MRADLs. The documentation is not clear that the patient's mobility deficit cannot be helped by the use of a walker, cane or manual wheelchair. There is no home evaluation indicating the patient can safely operate a PMD in the home. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for these services.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 pay forthe power mobility device and sales tax provided to the enrollee on July 13, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the rollator transport chair (E1399) purchased on October 30, 2019.You asked the Plan to pay for the rollator transport chair. You say that your doctor told you need to try to lose weight and you need to try and walk so you need a walker with a chair to  because your  legs will collapse easily. The Plan denied your request. The Plan says there is no Medicare assigned HCPCS code because this item is exceeds the enrollee's needs and is considered a luxury item and is not covered.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does is considered a luxury item under Medicare. While a rollator transport chair may be appropriate, neither the Plan nor Medicare offers coverage of this item.Therefore, we decided that the Plan does not have to pay for the rollator transport chair (E1399) purchased on October 30, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory infusion pump (E0781) provided on May 8, 2019.
You asked the Plan to pay for the ambulatory infusion pump. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says this is not separately payable as these infusions are started in a physician's office.
The Plan must follow Medicare rules. Medicare rules say that equipment used to begin administration of the drug or biological that the patient takes home to complete the infusion are not separately billable as durable medical equipment. You are requesting payment for rental of the pump used for this chemotherapy infusion. Separate payment for the equipment is not allowed. Therefore, we decided that the Plan does not have to pay for the ambulatory infusion pump (E0781) provided on May 8, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on October 2, 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 Healthcare Common Procedure Coding System (HCPCS) G0483 (1 Unit) remains not supported
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on October 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 18, 2019.
You asked the Plan to pay for the dental service. You say that the cleaning you had done was not covered. You say that you were surprised not even $1 was paid towards the service. You also say that you paid a $99 copayment at the time of service. The Plan denied your request. The Plan says periodontal maintenance is not a covered service.
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, periodontal maintenance is not among those covered under this benefit. Additionally, the record shows that you received this service on July 12, 2019 and the Plan denied payment then as well. Therefore, we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on November 18, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe inpatient psychiatric services provided on March 8, 2019 to March 25, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe inpatient psychiatric services. You say that you would like the paln to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program.Review of the file shows that the provider was not Medicare-certified during the dates of service at issue in this appeal. 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 forthe inpatient psychiatric services provided on March 8, 2019 to March 25, 2019 by an out of network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran injection procedure provided on December 16, 2019.You asked the Plan to waive the copayment foran injection procedure. You say that you were not informed that you would owe a $325 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 a $325 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $325 copayment for an injection procedure. Aninjection procedure falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran injection procedure provided on December 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided on March 16, 2019 to March 31, 2019 by an out of network (OON) provider.You asked the Plan to pay forhome health services. You say that your mother needed this care after a hip replacement.The Plan denied your request. The Plan says the member did not go with the recommended provider and used an out-of-network provider. The Plan says that 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 forhome health services provided on March 16, 2019 to March 31, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approvenursing care home registered nurse-hour in the home services (60 units).You asked the Plan to pre-approvenursing care home registered nurse-hour in the home services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested services are not medically necessary.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 nursing care home registered nurse-hour in the home services. Our reviewer says that the documentation does not support that the requested services are medically reasonable or necessary. Our physician reviewer found the enrollee has documented RDS and metabolic acidosis. The enrollee has known hyperbilirubinemia. The enrollee is also notable for scoliosis surgery in 2014 and is bedridden. The documentation does not indicate a skilled RN is needed above a non-skilled provider, capable of performing gastrostomy and tracheostomy care and monitoring vital signs for this ventilator-dependent enrollee. The documentation does not support that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of nursing care home registered nurse-hour in the home services have not been met.Therefore, we decided that the Plan does not have to pre-approvenursing care home registered nurse-hour in the home services (60 units).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network chiropractic care provided from October 8, 2019 to October 22, 2019. You asked the Plan to pay for out of network providers. You say that the provider told you they were in network. The Plan denied your request. The Plan says this provider is not in network and you did not have prior authorization for out of network care.
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 contract also says that chiropractic care requires a referral and the use of a specific provider. The 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 service 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 out of network chiropractic care provided from October 8, 2019 to October 22, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided on
November 25, 2019.
You asked the Plan to pay for extraspinal chiropractic manipulation. You say that this was medically necessary.
The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is
manual manipulation of the spine to correct a subluxation.
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided on November 25,
2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on August 23, 2019. You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the 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 did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for physician's services provided on August 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on December 2, 2019.
You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 December 2, 2019.