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

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on October 7, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services
rendered by non-participating providers in non-participating facilities require prior authorization as outlined in
the enrollee's EOC.
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 services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on October 7, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 4 power wheelchair (K0870).
You asked the Plan to pre-approve the Group 4 power wheelchair. You say that she is being seen for left ankle pain following multiple surgeries. She also has cervical and lumbar pain, lumbar spondylosis, lumbar degenerative disc disease, chronic compression fractures, and has been extensively treated by numerous specialists undergoing various surgeries and treatment plans. The Plan denied your request. The Plan says this is not the most appropriate mobility device for this enrollee.
The Plan follows Medicare rules. Medicare rules say that Group 4 PWCs have added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided they will be denied as not reasonable and necessary. The file shows that the Group 4 power wheelchair has added suspension features to help with mobility outside of the home. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 4 power wheelchair (K0870).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a mandibular bone grafting procedure.
You asked the Plan to pre-approve the bone grafting. You say that you state that this should be covered as medical since the enrollee has pain and infection throughout the mandible preventing her from functioning properly. This could also have a negative effect on her overall health if not treated. The Plan denied your request. The Plan says this is care for the teeth and cannot be covered by Medicare.
Medicare generally does not cover dental services. The Plan follows the same rule. In this case, the documentation provided is not sufficient to determine whether this service may be considered a covered treatment of an illness/injury. The documentation does not provide any information about the state of the enrollee's teeth, whether she has any teeth remaining, or if she uses or needs to use either a complete or partial denture. Without this information, it is not clear whether this request is primarily needed in order to care for teeth or supporting structures. The provider is responsible for submitting sufficient documentation to support whether coverage under Medicare is allowed, and the file as reviewed does not include enough information to make this determination. Therefore, we decided that the Plan does not have to pre-approve a mandibular bone grafting procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the ferric carboxymaltose injections provided on May 24, 2018 and May 31, 2018.
You asked the Plan to waive the coinsurance for the ferric carboxymaltose injections. You say that you paid the provider $250. You say that you don't believe you owe any money. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for chemotherapy drugs and 20% coinsurance for all other drugs covered under Medicare Part B from an in-network provider. You have been asked to pay $141.75, which is 20% of the allowed amount for each ferric carboxymaltose injection. The allowed amount is $708.75 (20% x $708.75 = $141.75). The total amount you owe is $283.50 ($141.75/injection x 2 injections = $283.50). The ferric carboxymaltose injections falls within the "Medicare Part B prescription drugs" benefit category.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the ferric carboxymaltose injections provided on May 24, 2018 and May 31, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 27, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.
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 services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on August 27, 2019.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

We decided that the Plan has to pre-approve routine eye exam. We decided that the Plan does not have to preapprove
eyeglasses (frames and lenses).
You asked the Plan to pre-approve a routine eye exam and eyeglasses. You say that you've had vision changes
and is having difficulty with your glasses and cannot see well with your left eye The Plan says that the enrollee
last used the eye wear and eye exam benefit on February 6, 2019 and will not be eligible for this benefit until
January 15, 2021.
We decided that the Plan has to pre-approve routine eye exam.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers for 1 routine eye exam a year. The records show the enrollee's last eye exam on
January 1, 2019. Therefore the enrollee is eligible for a routine eye exam. Therefore, we decided that the Plan
has to pre-approve routine eye exam.
We also decided that the Plan does not have to pre-approve eyeglasses (frames and lenses).
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan covers $300 for eyeglasses (frames and lenses) or contact lenses every 2 years. The records
show that you had received eyewear on February 6, 2019. Therefore you will not be eligible for the eye wear
benefit until February 6, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on April 23, 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 drug testing rendered to enrollee on April 23, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy, 60 minutes, provided on October 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient mental health services. The Plan denied your request. The Plan says authorization was not obtained before the service was provided to the enrollee. The Plan says that the enrollee self-directed for the service. The Plan also says that the service was 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 psychotherapy, 60 minutes, provided on October 23, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the heel or elbow protector (E0191) provided September 24, 2019.You asked the Plan to pay for the heel or elbow protector. You say that this elbow protector has proven effective in relieving the pain that you have been suffering for months and you request the plan to reverse the decision to deny the claim.The Plan denied your request. The Plan says this item is not a covered item.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal is 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 have to pay for the heel or elbow protector (E0191) provided September 24, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided on September 11, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that you would like this appeal reprocessed and
approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained for
these 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 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 chiropractic services provided on September 11,
2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided on October 30, 2019 by an out of network (OON) provider.You asked the Plan to pay for lab services. You say that you would like payment for the denied services that were provided.The Plan denied your request. The Plan says no prior authorization was obtained for these 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 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 lab services provided on October 30, 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 office visit provided on September12, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that a plan representative verified on September 12, 2019 that the provider in this case was in network with the enrollee's plan. You say that when you spoke to a plan representative on September 25, 2019, you were advised that the provider was out of network. You also say that the services were provided to the enrollee in good faith based on the initial correspondence with the ernollee's plan.The Plan denied your request. The Plan says authorization was not obtained before the services were rendered to the enrollee. The Plan also says the services were not urgent or emergent in nature.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-networkproviders 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 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 office visit provided on September 12, 2019 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 3,2019 to June 7, 2019 by an out of network (OON) 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-participating 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 May 3, 2019 to June 7, 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 drug testing services provided to the enrollee by an out-of-network provider on April 30, 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 stating exactly what tests are to be performed.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 by an out-of-network provider on April 30, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ilumya for enrollee.You asked the Plan to pre-approve Ilumya. You say that the enrollee has failed Enbrel and is having breakthrough severe flares.The Plan denied your request. The Plan says the enrollee has not failed to achieve symptom control after prior therapy with, or has intolerance with: Remicade or Inflectra; and Stelara.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 Ilumya. Our physician reviewer found that the enrollee has a diagnosis of psoriasis vulgaris. The Plan requires a trial of Remicade or Inflectra; and Stelara before they will approve the requested drug. The documentation does not show that the enrollee has not tried and failed the required drugs. The records do not state that Remicade or Inflectra; and Stelara would likely be less effective, 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 Ilumya have not been met. Therefore, we decided that the Plan does not have to pre-approve Ilumya for enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services provided on December 22, 2018.You asked the Plan to pay for the ambulance services. You say that the ambulance service was medically necessary.The Plan denied your request. The Plan says the enrollee could have been safely transported by another type of vehicle.Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules. 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 ambulance services. Our physician reviewer found the enrollee was transported from the hospital to a rehabilitation facility.  The enrollee has complex medical history including back pain and antibiotic resistance bacterial infection requiring contact precautions. The physician certification statement states the enrollee is unable to sit in chair or wheelchair.  There are no medical records available for review. The submitted documentation does not support that transport by methods other than ambulance are contraindicated.  Without the support of the documentation, medical necessity cannot be determined. The denial is upheld. 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 ambulance services have not been met.Therefore, we decided that the Plan does not have to pay for ambulance services provided on December 22, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95870), neuromuscular junction testing (95937) and somatosensory testing (95938) provided on December 2, 2019.You asked the Plan to pay for the needle electromyography, neuromuscular junction testing and somatosensory testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the professional interpretation of a diagnostic test must be separately billed with modifier -26 by the interpreting physician.The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the technical component (TC) of radiology services furnished to hospital patients.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the needle electromyography, neuromuscular junction testing and somatosensory testing have not been met. Specifically, these services were billed with the TC modifier. The TC component of radiology services furnished to hospital patients is paid to the hospital. Therefore, we decided that the Plan does not have to pay for needle electromyography (95870), neuromuscular junction testing (95937) and somatosensory testing (95938) provided on December 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 11, 2019 to the enrollee by an out of network (OON) 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-participating 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 September 11, 2019 to the enrollee by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).You asked the Plan to pre-approve Prolia. You say that the requested medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.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 Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Zoledronic acid 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 Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897).