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

We decided that the Plan does not have to pre-approve specialist services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve specialist services. You say that you felt like the doctor they referred you too was not interested in helping you. You say that you would like to see the doctor you have used before. The Plan denied your request. The Plan says there are in-network providers available.
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 care that cannot be provided by network providers. 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. Please contact the Plan for a list of qualified in-network providers. 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-approve specialist services to be provided by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Beovu.
You asked the Plan to pre-approve Beovu. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not medically necessary.
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 Beovu. Our reviewer says that the documentation does not support that the requested drug, Beovu is medically reasonable or necessary. Our physician reviewer found the documentation does not support that the enrollee has had a trail and failure of bevacizumab. The documentation does not support that Bevacizumab 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 Beovu have not been met. Therefore, we decided that the Plan does not have to pre-approve Beovu.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 1, 2019 to October
29, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that the enrollee was told that you are an in-network
provider. The Plan denied your request. The Plan says the denial of payment for these services is correct,
because this provider is out-of-network with the Plan and authorization 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,
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 the medical services provided on October 1, 2019
to October 29, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 20, 2019 by an out of network (OON) provider.
You asked the Plan to pay for laboratory tests. You say that this testing was ordered by an in-network provider. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering provider is also out-of-network with 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 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 medical services provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora surgical procedure of the spine provided on December 3, 2019.You asked the Plan to waive the copayment fora surgical procedure of the spine. You say that you have never been charged in the past and disagree with the charges.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 $300 copayment for each visit to an outpatient hospital facility. You have been asked to pay a $300 copayment for a surgical procedure of the spine. A surgical procedure of the spine 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 fora surgical procedure of the spine provided on December 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 22, 2019 by an out of network (OON) provider.
You asked the Plan to pay for vision services. You say that you believed this provider accepted this insurance. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with 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 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 medical services provided on October 22, 2019 by an out of network (OON) 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 3, 2019.
You asked the Plan to waive the copayment for the office visit. You say that the visit was for test results. You say that this was not coded correctly. 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 $25 copayment for each in-network specialist visit for Medicare-covered benefits. You have been asked to pay a $25 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 you were examined and assessed during the office visit. 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 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an electronic connection, expandable controller and expandable controller harness for the enrollee.You asked the Plan to pre-approve these services. The Plan denied your request. The Plan says that the enrollee's upper limb strength and function are adequate for the member to be able to control the power options using their own switches which are included in the allowance of these power options.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 pre-approve these services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. The documentation does not reveal that the patient requires a proportional input device, an attendant control, other electronic devices such as augmentative speech device, a separate display, a non-proportional input device such as sip and puff, or the need to control three or more power seating actuators through the drive control. The patient's strength and function as documented by her physician is sufficient to control the power options with their separate switches already included with the approval of these power options. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of an electronic connection, expandable controller and expandable controller harness.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-approve an electronic connection, expandable controller and expandable controller harness for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services provided on August 16, 2019 to October 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services received 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 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 the chiropractic services provided on August 16, 2019 to October 18, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Power wheelchair, group 2 standard (K0820).
You asked the Plan to pre-approve a Power wheelchair, group 2 standard. You say that you are an amputee and
have only one foot and you have a sore on your foot and need to keep the pressure off. The Plan denied your
request. The Plan says this enrollee does not meet the Medicare criteria.
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 pre-approve a Power wheelchair, group 2 standard.
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in
this case. Our physician reviewer found the enrollee has a personal mobility deficit but the documentation does
not reveal that this deficit impairs participation in mobility related activities of daily living. The enrollee is able
to use a manual wheelchair to participate in and be independent with all basic activities of daily living per a
physical therapy assessment on 2/14/20. The documentation indicates the enrollee can safely navigate a manual
wheelchair in her home but the documentation is not clear that the enrollee can safely operate a power mobility
device within her home.
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 Power wheelchair, group 2 standard have not been met. Therefore, we decided
that the Plan does not have to pre-approve a Power wheelchair, group 2 standard (K0820).
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for a shoulder x-ray (73020) provided on November 4, 2019.
You asked the Plan to pay for the x-ray. You say that you would like reconsideration because this claim denied as a duplicate in error. The Plan denied your request. The Plan says that CPT code 73020 is a column II procedure to the column I procedure.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code 73020 is supported in the record. Specifically, CPT code 73020 was rendered by a different provider with a separate NPI. Based on this information, we decided that Medicare rules for coverage of the x-ray have been met. Therefore, we decided that the Plan has to pay for a shoulder x-ray (73020) provided on November 4, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 20, 2019.
You asked the Plan to waive the copayment for the emergency room visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency room visit. The emergency room visit falls within the "Emergency care" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit provided on September 20, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the left hip.You asked the Plan to pre-approvethese services.. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only 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 to pre-approve these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted documentation does not include a detailed physical examination of the hip, discussion of conservative treatments, analgesia, or previous imaging. There is also no discussion of differential diagnosis of plan of care pending the MRI results. The requested MRI is therefore not reasonable or medically 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 these services. have not been met.Therefore, we decided that the Plan does not have to pre-approvemagnetic resonance imaging (MRI) of the left hip.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee x-ray, 4 or more views, provided on October 7, 2019.You asked the Plan to pay for the x-ray. You say that  The Plan denied your request. The Plan says The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. The Plan also says that during the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for the knee x-ray, 4 or more views, provided on October 7, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe dental services you received on December 12, 2019.You asked the Plan to pay forthe dental services. You say that radiation treatments cause tooth decay.The Plandenied your request. The Plan says you have met your annual maximum benefit.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. We looked at the file, and Medicare rules. The records show that prior to the services at issue in this appeal, you had exhausted your maximum annual allowance for this benefit. Based on this information, we decided that the Plan's rules forcoverage of the dental services have not been met. Therefore, we decided that the Plan does not have to pay forthe dental services you received on December 12, 2019.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to waive the copayment applied to eye care services provided on December 3, 2019.
You asked the Plan to waive the copayment applied to the eye care services. You say that you were told that you would have a $0 copayment for the retinopathy test screening you received. You say that the Evidence of Coverage does not state that you have to be diagnosed with retinopathy first, in order to get the free exam. The Plan denied your request. The Plan says that the services provided fall under a medical diagnostic visit and the $35 copayment was appropriately applied.
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, there were no medical records provided, nor was their evidence of reasonable attempts made by the Plan to obtain this documentation. The claim form shows that the enrollee has a diagnosis of diabetes. Without medical records, the Plan has not substantiated their reason for applying a $35 copayment to the visit which the enrollee claims was a retinopathy test screening. We are unable to verify that the copayment in dispute was appropriately applied to the services which were provided. Therefore, we decided that the Plan has to waive the copayment applied to eye care services provided on December 3, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided on December 9, 2019.You asked the Plan to waive the copayment for physical therapy. You say that you were not there on this date. You say that you shouldn't have to pay for a service you didn't have.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 $40 copayment for Medicare covered physical therapy visits.You have been asked to pay a $40 copayment for physical therapy. Physical therapy falls within the "Outpatient rehabilitation services" benefit category. The records show that you received physical therapy on December 9, 2019. 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 forphysical therapy provided on December 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a total electric hospital bed and a power pressure-reducing air mattress.
You asked the Plan to pre-approve a total electric hospital bed and a power pressure-reducing air mattress. You say that the enrollee has weakness and cannot manually adjust the bed to get in and out of. The Plan denied your request. The Plan says total electric hospital beds are not covered by Medicare and the enrollee does not meet criteria for a power pressure-reducing air mattress.
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. The record does not mention the enrollee has had or has pressure ulcers. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital bed and a power pressure-reducing air mattress.