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

We decided that the Plan has to waive the coinsurance forrabies injections provided on May 20, 2019.You asked the Plan to waive the coinsurance forthe rabies injections. You say that youwent to the emergency room and were told you did not have to pay because the provider is contracted with your insurance.The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $90 copayment for each Medicare-covered emergency room visit in-network and out-of-network. The Plan says you must pay a total coinsuranceamount of $512.43for the rabies injections. Based on the Plan contract, however, you cannot be asked to pay more than $0 coinsurance for the rabies treatments.The record shows you received emergency services and the injections are included in the emergency room copayment. Therefore, we decided that the Plan has to waive the coinsurance forthe rabies injections provided on May 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided by an in-network provider, from July 6, 2019 through July 12, 2019.You asked the Plan to waive the copayment forinpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received due to the care you received.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 inpatient hospital care provided by an in-network provider from July 6, 2019 through July 12, 2019.You are asked to pay a $295 copayment per day from July 6, 2019 through July 9, 2019, days 1-4 of your inpatient stay. There were no copayment charges from July 10, 2019, day 5 of your inpatient hospital care until your day of discharge July 12, 2019. Per your contract there is a $295 copayment per day required for days 1-4. 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 topay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment forinpatient hospital care provided by an in-network provider, from July 6, 2019 through July 12, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are undergoing chemotherapy which causes severe dizziness. The shower chair is for your safety when taking a shower and to prevent another fall. You say that you have already fallen once and had to go to the hospital. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on February 27, 2019.You asked the Plan to pay for the testing. 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 testing have not been met.Therefore, we decided that the Plan does not haveto pay fordrug testing services provided to the enrollee on February 27, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Synvisc-One.
You asked the Plan to pre-approve Synvisc-One. You say that Medicare covers Synvisc-One without prior authorization or step therapy. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Orthovisc and Monovisc before it will approve Synvisc-One.
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 Synvisc-One. Our reviewer says that you do not meet the Medicare criteria for a step therapy exception for Synvisc-One. Our physician reviewer found the records do not indicate that you have tried and failed the Plan's preferred drugs of Orthovisc or Monovisc, and the records do not indicate that the Plan's required drugs would likely be less effective and/or have adverse effects for you. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Synvisc-One.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) with full leg sleeve (E0651 & E0671) to be provided by out of network provider, Medical Supply Cabinet, Inc.
You asked the Plan to pre-approve the OON PCD with leg sleeve. You say that there is no network provider within a reasonable distance. You state that you were not able to contact Duramed and that their website does not list PCDs as an item they offer. In addition, you state that the representative at CCS Medical did not know what a lymphedema pump was. The Plan denied your request. The Plan says both Duramed and CCS Medical were contacted and confirmed that the codes at issue could be provided if an order were received from the treating physician.
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 attested to having confirmed that there are network providers available who can provide the items/services at issue in this appeal. We note that there is a counterclaim which indicates that the two providers offered by the Plan cannot provide the items at issue. At this time, there is no evidence that the enrollee's physician submitted an order to either of the two network providers listed. Without clear evidence that the network suppliers are not able to provide this equipment, we find no exception that would require the Plan to pre-approve these items OON. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device (PCD) with full leg sleeve (E0651 & E0671) to be provided by out of network provider, Medical Supply Cabinet, Inc.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on July 10, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the stay was medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided on July 10, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface and humidifier, heated, used with positive airway pressure device.
You asked the Plan to pre-approve a respiratory assist device (E0471) and humidifier (E0562). You say that the respiratory assist device and humidifier are medically necessary. The Plan denied your request. The Plan says that the respiratory assist device and humidifier are not medically necessary because of the diagnosis.
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD. 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 a respiratory assist device (E0471) and humidifier (E0562). Our reviewer says that the respiratory assist device and humidifier are medically necessary. Our physician reviewer found coverage criteria for a BiPAP ST device are met. This enrollee has obstructive sleep apnea, originally documented on polysomnography 8/7/2015. Titration studies of both continuous positive airway pressure (CPAP) and BiPAP have been unable to find pressures that eliminate the sleep disordered breathing. Currently the enrollee has persistent sleep symptoms despite consistent use of BiPAP. The most recent PAP study suggests the emergence of central apneas while on BiPAP. Thus a BiPAP ST device, with a backup rate feature, is considered medically necessary. The denial is overturned. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a respiratory assist device (E0471) and humidifier (E0562) have been met. Therefore, we decided that the Plan has to pre-approve a respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface and humidifier, heated, used with positive airway pressure device.
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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the x-ray provided on August 22, 2019.
You asked the Plan to waive the copayment for the x-ray. You say that the x-ray was done at a free standing
building. You say that the copayment should be $40. 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 a $50
copayment for each Medicare-covered x-ray in an in-network outpatient hospital facility.
You have been asked to pay a $50 copayment for the x-ray. The x-ray falls within the "Outpatient diagnostic
tests and therapeutic services and supplies" benefit category. The records show that the x-ray was billed by the
hospital. 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 x-ray provided on August 22, 2019.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for outpatient hospital services provided on June 5,
2019.
You asked the Plan to reimburse you for the outpatient hospital services. The Plan denied your request. The
Plan says proof of payment has not been provided. Without the proof payment the Plan cannot substantiate the
amount paid and verify the charges.
The Plan must follow Medicare rules. Medicare rules say that Medicare says that health plans must pay for
emergency and urgently needed services. The Plan contract says that coverage for urgently needed care
worldwide is a supplemental benefit. You must sent the Plan the bill along with documentation of any
payments you have made.
We looked at the file and Medicare rules. The file shows that proof of payment has not been provided to the
Plan. Without the proof payment the Plan cannot substantiate the amount paid and verify the charges.
Therefore, we decided that the Plan does not have to reimburse you for outpatient hospital services provided on
June 5, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

he rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 CFR 422.101.
The rules say that incontinence supplies are not covered because they are hygienic items that are non-reusable. You can find this rule in the Medicare National Coverage Determinations Manual, Section 280.1.
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.
Explanation of decision
We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that you need the requested briefs due to your urinary incontinence. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee by laboratory on July 9, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 laboratory services rendered to the enrollee by the laboratory on July 9, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic test (93295) provided on July 29, 2019.
You asked the Plan to waive the copayment for the diagnostic test. You say that you feel you should not be responsible for this cost share amount and you would like the plan to reconsider your request. The Plan denied your request. The Plan says you received outpatient diagnostic services on the date of service at issue in this appeal. The plan states the correct copayment has applied per your contract with the plan.
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 $20 copayment for Medicare-covered tests. We looked at the file, the Plan's contract and Medicare rules. The file shows you received a diagnostic test on July 29, 2019. You have been asked to pay a $20 copayment for the diagnostic test. The diagnostic test falls within the Outpatient diagnostic tests 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 diagnostic test (93295) provided on July 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvechair stair lift and wheelchair rampYou asked the Plan to pre-approvechair stair liftand wheelchair ramp. You say that you need a wheelchair ramp to get the enrollee in and out of the house and a stair lift to be able to go between the different levels of the home independently.The Plan denied your request. The Plan says these items do not meet the definition of durable medical equipment, do not serve a medical purpose and is not covered by MedicareThe Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  Theitems at issue in this appeal does not serve a purpose that is primarily medical in nature. These items are available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not haveto pre-approvechair stair lift and wheelchair ramp
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on June 10, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on June 10, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve eight physical therapy visits.
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your request. The Plan says there is no skilled need currently.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the requested therapy generally is not accepted as specific and effective therapy for your condition. The documentation indicates your progress is limited by pain. You have had prior therapy for this condition. Your functional level does not require the unique skills of a professional therapist to safely and effectively provide treatment. Services do not need to be only safely and effectively performed by a therapist, or under the supervision of a therapist. The requested services are not part of a maintenance program to maintain your current condition or to prevent or slow further 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 the visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight physical therapy visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the test strips, lancets, control solution, and lancet device provided from July 22, 2019 to October 10, 2019.
You asked the Plan to pay for the test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the test strips, lancets, control solution, and lancet device provided from July 22, 2019 to October 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on August 14, 2019 by the out of network provider.
You asked the Plan to pay for the physician services. You say that the enrollee presented their Medicare card at the time of service. The Plan denied your request. The Plan says authorization was not obtained before the services were provided to the enrollee. The Plan says the enrollee's primary care physician did not refer them for the services. The Plan also says the services were 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 pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the office visit provided on August 14, 2019 by the out of network provider.