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

We decided that the Plan does not have to pay forphysician services provided on October 9, 2019 byYou asked the Plan to pay forthis service. You say that this service should be covered.The Plan denied your request. The Plan says 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 mustpay 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 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 forphysician services providedon October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis provided on September 10, 2019.You asked the Plan to pay forthe ankle foot orthosis (L1971). You say that the orthosis was medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.The Plan must follow Medicare rules. Medicare rules saythat 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 forthe ankle foot orthosis provided on September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the AlloSure test provided to the enrollee on December 11, 2018.
You asked the Plan to pay for the test. You say that this is a covered service for Medicare beneficiaries, is medically necessary, and the results of which were used in the course of the enrollee's treatment post-transplant. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 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 the test. Our reviewer says that the test at issue in this case was not medically reasonable or necessary. Our physician reviewer found the use of donor-derived cell-free DNA (e.g., AlloSure) to assess the probability of allograft rejection in kidney transplant recipients with clinical suspicion of rejection is considered investigational. The review has determined that the enrollee does not meet the criteria for the AlloSure test. 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 test have not been met. Therefore, we decided that the Plan does not have to pay for the AlloSure test provided to the enrollee on December 11, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from July 31, 2019 through August 1, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that the copay is too high because the member was only there for 12-13 hours. The Plan denied your request. The Plan says they confirmed a request for inpatient hospital services was received from the provider and approved by the Plan. A letter dated July 31, 2019 was sent advising the approval of inpatient hospital services.
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 the enrollee received inpatient hospital care provided from July 31, 2019 through August 1, 2019. At the time of services rendered the enrollee had met their $750 deductible; therefore, the enrollee has been asked to pay a $300 copayment for the inpatient hospital care. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for inpatient hospital care provided to the enrollee from July 31, 2019 through August 1, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement continuous positive airway pressure
(CPAP) device.
You asked the Plan to pre-approve a new CPAP device. You say that you need a CPAP. The Plan denied your
request. The Plan says more recent clinical documentation was requested but not received from your physician.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file, and Medicare rules. There is no current documentation from your treating practitioner
that you are compliant and benefiting from a CPAP device. Based on this information, we decided that
Medicare rules for coverage of a new CPAP device have not been met. Therefore, we decided that the Plan
does not have to pre-approve a replacement continuous positive airway pressure (CPAP) device.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for CPT 84443. We decided that the Plan does not have to pay for CPT 83036, 82728, 83550, 84466, and 83540. You asked the Plan to pay for the services. You say that this should be paid for.The Plan says that Medicare says tests with no relation to a medical diagnosis of disease for the health of the patient are not a benefit.We decided that the Plan has to pay for CPT 84443. The Plan follows Medicare rules. Medicare rules say that services are covered when they are medically 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 for CPT 84443. Our reviewer says that CPT 84443 is medically reasonably and necessary with its association with ICD-10 25.2.We looked at this physician's review, the file, and Medicare rules.Based on this information, we decided that Medicare rules for coverage of CPT 84443 have been met.Therefore, we decided that the Plan has to pay for CPT 84443. We also decided that the Plan does not have to pay for CPT 83036, 82728, 83550, 84466, and 83540.The Plan follows Medicare rules. Medicare rules say that services are covered when they are medically 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 for the remaining codes. Our reviewer says that the labs in question were associated with ICD-10 codes Z70.00 and R 25.2. CPT 83036, 82728, 83550, 84466, 83540 are not medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CPT 83036, 82728, 83550, 84466, and 83540 have not been met.Therefore, we decided that the Plan does not have to pay for CPT 83036, 82728, 83550, 84466, and 83540.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: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Bimatoprost 0.03% eye drops for the enrollee.You asked the Plan to pre-approvethe drops. You say that this is medically necessary.The Plan denied your request. The Plan says this is a medical only policy with the plan.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 arecovered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approve Bimatoprost 0.03% eye drops for the enrollee.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the next-generation sequencing (NGS) rendered on July 8, 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 that the services were not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that NGS is covered when specific criteria are met. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were medically necessary. Our physician reviewer found the enrollee has suspected recurrence of uterine cancer in the omentum. The enrollee has either recurrent or relapsed, metastatic, or advanced stage III or IV cancer. She has not been previously tested using the same NGS test for the same primary diagnosis of cancer. Further cancer treatment is expected to be guided by the results of this testing. The testing was reasonable and medically necessary for the enrollee. 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 pay for the next-generation sequencing (NGS) rendered on July 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to provide a lightweight manual wheelchair.
You asked the Plan to provide a lightweight manual wheelchair (K0003). You say that because of a medical condition the enrollee is short of breath and weak and needs a manual wheelchair. The Plan denied your request. The Plan says there was no home assessment or evaluation on ability to self-propel the requested wheelchair.
The Plan follows Medicare rules. Medicare rules say that for any item to be covered by Medicare it must meet all applicable Medicare statutory and regulatory requirements. The file does not show that that the enrollee's home provides adequate access or that the enrollee can safely self-propel the manual wheelchair. Documentation was requested by the plan but not received. This means that Medicare rules for coverage of a manual wheelchair have not been met. Therefore, we decided that the Plan does not have to provide a lightweight manual wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Botox injection.
You asked the Plan to pre-approve a Botox injection. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that Botulinum Toxin is covered for the treatment of overactive bladder with symptoms of urge urinary incontinence, urgency, and frequency, in adults who have an inadequate response to or are intolerant of an anticholinergic medication. 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 Botox injection. Our reviewer says that a Botox injection is not medically reasonable and necessary. Our physician reviewer found that the enrollee is noted to have interstitial cystitis (IC). While symptoms associated with interstitial cystitis include dysuria and frequency, there is no evidence that the enrollee specifically has an overactive bladder or urinary spasm/spasticity. As such, the documentation does not support the use of the requested drug. 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 Botox injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a Botox injection.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for prostate specific antigen tests (84153), a tissue exam (88305), and a biopsy (55700) provided from August 19, 2019 to August 29, 2019.You asked the Plan to pay forprostate specific antigen tests, a tissue exam, and a biopsy. You say that you required urgent medical care.The Plandenied your request. The Plan says that these services were not urgent.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, no documentation was provided to substantiate that these services were not urgent. Although the Plan states that medical records were received and reviewed, these records were not included in the file. Without medical records that demonstrate the urgency or lack thereof of these services, the Plan denial cannot be substantiated and we must find in your favor.Therefore, we decided that the Plan has to pay forprostate specific antigen tests (84153), a tissue exam (88305), and a biopsy (55700) provided from August 19, 2019 to August 29, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is medically stable for transfer. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that the enrollee is apparently undergoing treatment at an acute care hospital (ACH) for heart failure, requiring a chronic dobutamine infusion. The enrollee does not appear to be intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on September 21, 2019.
You asked the Plan to waive the copayment for the MRI. You say that this came from an error with your primary care physician's office. You say that you are appealing the copayment amount. 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 $275 copayment for Medicare-covered diagnostic radiology services. You have been asked to pay $271.63, which is less than the standard $275 copayment for the MRI. The MRI falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 MRI provided on September 21, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe lumbar-sacral orthosis and ankle foot orthosis provided on July 8, 2019.You asked the Plan to pay forthe lumbar-sacral orthosis (L0650) and the ankle foot orthosis (L1971). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says rules for telehealth services were not met.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 forthe lumbar-sacral orthosis and ankle foot orthosis provided on July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 29, 2019.
You asked the Plan to pay for the physician's services. You say that the doctor's staff told you they accepted Medicare when you gave them your cards. 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 services. Therefore, we decided that the Plan does not have to pay for physician's services provided on May 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiology services (72100, 73502, 71046) provided on August 29, 2019 by out of network provider.You asked the Plan to pay forthe radiology services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were non-emergent and not pre authorized. There were contract providers available in the area who could perform the same services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that thePlan 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 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 forthe radiology services (72100, 73502, 71046) provided on August 29, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on October 9, 2019.You asked the Plan to waive the copayment for the office visit. You say that you went in for testing and did not have an office visit. You say that you should not be billed.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 $20 copayment for each specialist visit for Medicare-covered benefits.You have been asked to pay a $20 copayment for the office visit. The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show that the services were provided by a specialist. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the office visit provided on October 9, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Restasis.You asked the Plan to pre-approve Restasis. You say that the enrollee has been on Restasis for three years.The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient 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-approveRestasis. Benefits for Restasismay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xtampza ER for the enrollee.
You asked the Plan to pre-approve this drug. The Plan denied your request. The Plan says that this is not covered under Part B.
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 Xtampza ER for the enrollee.
Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.