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

We decided that the Plan does not have to payforthe medical services provided on November 7, 2019 to December 6, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe out of network medical services. You say that you may as well not have insurance and live with pain and hurt the rest of your life. You say that the insurance company is hurting you more than the surgeries. You say that you do not have the money to pay for these services. You say that you gave the provider all of your information and they said they would bill your insurance company. You say that this is not the first time this has happened to you. You say that you only go to the doctor if there is something wrong with you.The Plan denied your request. The Plan says is out of network and there was no authorization obtained for coverage with this provider.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 forthe medical services provided on November 7, 2019 to December 6, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CYP panel rendered on October 7, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not billed correctly.The Plan must follow Medicare rules. The rules say that all CYP panels should be billed with 81479 and are non-covered.The testing at issue is a CYP panel. The file shows that the testing was not billed with the required 81479 code. Furthermore, this testing is not covered by Medicare.Therefore, we decided that the Plan does not have to pay forthe CYP panel rendered October 7, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 25, 2019 to the enrollee by a non-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were rendered by a non-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The referring provider 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 25, 2019 to the enrollee by a non-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveBotox (onabotulinumtoxina), 100 units, 1 dose every 3 months.You asked the Plan to pre-approveBotox. You say that you havebeen hospitalized and taken several round of antibiotics for urinary tract infections (UTIs). You say that yourtreating physician feels Botox might help youwith this issue. You also say that you havedeveloped immunity to certain antibiotics.The Plan denied your request. The Plan says the Botox is not medically necessary.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Botox. Our reviewer says that the Boxtox is not medically necessary. Our physician reviewer found the documentation provided does not include a detailed history or objective testing to support yourdiagnosis. The reviewer found that without the support of the documentation, medical necessity cannot be determined.We looked at thisphysician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met.Therefore, we decided that the Plan does not have to pre-approveBotox (onabotulinumtoxina), 100 units, 1 dose every 3 months.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay fora rabies vaccine provided to the enrollee on November 1, 2019 to November 4, 2019.You asked the Planto pay forthe drugs. You say that this should be paid for.The Plandenied your request. The Plansaysthe services were correctly denied.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the drugs. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the drugs.Therefore, we decided that the Plandoes not haveto pay fora rabies vaccine provided to the enrollee on November 1, 2019 to November 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services
You asked the Plan to pay for the OON services. You say that the service was sent by an authorized provider. The Plan denied your request. The Plan says non-emergent services by non-participating providers require prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the lab services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the lab services
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve custodial care services.You asked the Plan to pre-approve the services. You say that this is medically necessary.The Plan denied your request. The Plan says this is not a covered benefit per the benefits master list, is not approved.The Plan must follow Medicare rules. The rules say that custodial care services 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 the services. Our reviewer says that  Our physician reviewer found 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 services have not been met.Therefore, we decided that the Plan does not have to pre-approve custodial care services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on September 24, 2019 by an out of network (OON) provider.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The 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 September 24, 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 lab services provided on November 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says the enrollee's plan requires utilization of network providers, and authorization for certain services.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the lab services provided on November 18, 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 copayments fora specialist visit and an X-ray provided on October 29, 2019.You asked the Plan to waive the copayments fora specialist visit and an X-ray. You say that you 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 $50 copayment per specialist visit. Your contract with the Plan also clearly says that you must pay a $15 copayment for X-rays.You received a specialist visit on October 29, 2019. Therefore, you are responsible to pay the $50 copayment. You received an X-ray on October 29, 2019. Therefore, you are responsible to pay the $15 copayment. The total amount you owe is: $65. You have beenasked to pay the total copayment amount of $65 for a specialist visit and an X-ray. A specialist visit falls within the physician/practitioner services, including doctor's office visits benefit category. An X-ray falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. This means that you have beenasked 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 copayments fora specialist visit and an X-ray provided on October 29, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran ECG provided on November 21, 2019.You asked the Plan to waive the copayment foran ECG. You say that this waspart of your annual wellness visit and you should not be responsible for 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 $20 copayment for outpatient diagnostic tests. You received an ECG on November 21, 2019. ECG's are not included in annual wellness visits. Therefore, you are responsible to pay your share of the cost-sharing charges. You have been asked to pay the allowed amount is $19.42, which is less than the $20 copayment for outpatient diagnostic tests for an ECG. an ECG 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 foran ECG provided on November 21, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Krystexxa (J2507).
You asked the Plan to pre-approve Krystexxa. You say that Krystexxa is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says there is no evidence that this member has tried and failed urate lowering therapies such as allopurinol or febuxostat.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Krystexxa. Our reviewer says that based on the medical records provided the documentation does not support that the Krystexxa is medically reasonable and necessary for the member. Our physician reviewer found Krystexxa is not indicated unless the patient has failed maximum dose xanthine oxidase inhibitor therapy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Krystexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Krystexxa (J2507).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Contour Next test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that you have to do multiple sticks when using the preferred brand. The Plan denied your request. The Plan says there is no medical reason documented that you are medically unable to use the Plan preferred test strips.
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 physician documentation that the non-preferred brand is necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Next test strips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflexprocedure).You asked the Plan to pre-approve Vertiflex procedure. You say that this is medically necessary and appropriate for the enrollee.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because the enrollee does not meet the indications for this procedure.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 Vertiflex procedure. Our reviewer says that the enrollee does not meet the Medicare criteria for Vertiflex. Our physician reviewer found the indications for the Vertiflex implant include patients suffering from pain, numbness, and/or cramping in the legs secondary to a diagnosis of moderate lumbar spinal stenosis, with or without grade 1 spondylolisthesis, confirmed by imaging. In this case, the enrollee does not meet the inclusion criteria for the requested procedure.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Vertiflex procedure have not been met.Therefore, we decided that the Plan does not have to pre-approve insertion of an interspinous spacer device (Vertiflex procedure).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids providedon January 10, 2020.You asked the Plan to pay for the hearing aids. The Plan denied your request. The Plan says you must see a in network provider to use the routine hearing aid benefit.Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when provided by a in network provider.We looked at the file and the Plan's rules. The provider at issue in this appeal is not a Plan hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for hearing aids providedon January 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 21, 2019 by an out of network (OON) provider.You asked the Plan to pay for these services. You say that you were not told that the provider was out-of-network until after the services were performed.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider without prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The 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 May 21, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on December 10, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe OON services. You say that there is a medical necessity pre-established with the enrollee and the facility.The Plan denied yourrequest. The Plan says there is no valid referral for this service.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 ith 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 services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay forthe medical services provided on December 10, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forhome health services provided to the enrollee from December 3, 2019 to December 10, 2019 and billed under code S9328.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare billing criteria were not met regarding an issue with the Status Code Indicator.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. In this case, the code billed has a status code indicator of "I" which that does not allow payment on Medicare claims.Therefore, we decided that the Plan does not have to pay forhome health services provided to the enrollee from December 3, 2019 to December 10, 2019 and billed under code S9328.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora power scooter purchased out of network from a Non-Medicare eligible provider on October 23, 2019.You asked the Plan to pay forthis equipment. You say that you purchased from this provider because the equipment was cheaper than other places.The Plan denied your request. The Plan says you purchased a power scooter out of network from a Non-Medicare eligible provider. You did not follow the Plan contract or the Medicare coverage criteria when you purchased this equipment.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a provider is not a Medicare program eligible provider. This equipment was purchased both out of network and from a provider who is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay fora power scooter purchased out of network from a Non-Medicare eligible provider on October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on September 17, 2019.You asked the Plan to pay forthese services.You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 64484 is not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must reportservices with the appropriate CPT code.In this case, the CPT Code Manual definition of code 64484 is injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional level (List separately in addition to code for primary procedure).We find that CPT code 64484 is not supported in the medical record. Specifically, the procedure note does not indicate that an injection at only one level was performed. 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 services rendered on September 17, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the heart (75571).You asked the Plan to pre-approve the CT scan. You say that the CT scan is medically necessary.The Plan denied your request. The Plan says rules for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 the CT scan. Our reviewer says that the CT scan is not medically necessary. Our physician reviewer found the enrollee has a family history of heart disease. The enrollee does not himself have cardiac signs or symptoms. The requested testing is not expected to change the enrollee's cardiac risk or treatment.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 CT scan have not been met.Therefore, we decided that the Plan does not have to pre-approve Computed Tomography (CT) of the heart (75571)