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

We decided that the Plan does not have to pay for the physician services provided on July 31, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services received were neither emergent nor urgent and prior authorization was not obtained to seek 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 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 physician services provided on July 31, 2019 by an out of network (OON) provider.
Your concern about having this provider become your PCP is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion of Prolastin-C.
You asked the Plan to pre-approve the Prolastin-C. You say that you would like reconsideration because the home infusion of Prolastin-C is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says this medication is covered under Medicare Part D.
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 home infusion of Prolastin-C.
Benefits for the Prolastin-C may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on July 30, 2019 by an out of network (OON) provider.You asked the Plan to pay foroffice visit. You say that you were not aware that this provider did not accept this Plan.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and prior 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 thisappeal. 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 July 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 for the medical services provided to the enrollee by an out-of-network provider on August 3, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services could have been provided in-network.
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 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Trulance tablets.
You asked the Plan to pre-approve self-administered drugs. You say that you are appealing. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.
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 Trulance tablets.
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for determination of refractive state (92015) provided on December 5, 2019.
You asked the Plan to pay for the services. You say that even though you had a refraction test earlier in the year the provider wanted to do one for himself in order to see you and continue treatment. The Plan denied your request. The Plan says you exhausted your benefit.
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. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of the services have not been met. You exhausted your benefit, because the initial test was done on March 26, 2019. Your EOC clearly states, there is only coverage for one (1) per year. Therefore, we decided that the Plan does not have to pay for determination of refractive state (92015) provided on December 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Nitroglycerine spray (A9270) provided on November 7, 2019.
You asked the Plan to pay for this medication. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says this medication is not a covered benefit under your contractual policy. This medication is considered a self-administered drug that will need to be processed under your Part D prescription drug benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug provided here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the Nitroglycerine spray (A9270) provided on November 7, 2019.
Benefits for this medication may be available under Medicare Part D. Contact the 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 waive the coinsurance for the injection provided on November 7, 2019.
You asked the Plan to waive the coinsurance for the injection. You say that you were informed the injection would be fully covered. 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% of the total cost for other Medicare-covered Part B prescription drugs. You have been asked to pay $93.12, which is 20% of the allowed amount for the injection. The allowed amount is $465.61 (20% x $465.61 = $93.12). The injection 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 injection provided on November 7, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an Emergency Room (ER) visit on January 2, 2020.
You asked the Plan to waive the copayment for the ER visit. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct cost sharing was applied.
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 ER visit. The ER 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 an Emergency Room (ER) visit provided on January 2, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Computed Tomography (CT) of the Neck (70491).
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 are not 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 at this time. Our physician reviewer found the physician was unable to palpate lymphadenopathy on physical exam. The documentation reviewed does not discuss laboratory findings or differential diagnosis. 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 Neck (70491).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 13, 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 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 August 13, 2019
to the enrollee by a non-network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for clotrimazole cream and betamethasone dipropionate cream provided on October 1, 2019.
You asked the Plan to pay for these drugs. The Plan denied your request. The Plan says that these drugs are not covered under 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 are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for clotrimazole cream and betamethasone dipropionate cream provided on October 1, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copay forthe routine transportation trips provided from October 22, 2019 to November 21, 2019.You asked the Plan to waive the copay forthe routine transportation trips. You say that you cannot afford this.The Plan denied your request. The Plan says that there is a $10 copay per one way trip.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 $10 copay per one way routine trip. You have been asked to pay a $10 copay for each routine transportation trips. The routine transportation trips fall within the per one way trip 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 copay forthe routine transportation trips provided from October 22, 2019 to November 21, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 6, 2019 through December 10, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC benefits.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Review of the file shows that you were admitted on December 6, 2019 and discharged on December 10, 2019. You were asked to pay a $225 copayment per day from December 6, 2019 through December 9, 2019, days 1-4 of your inpatient hospital care. You were discharged on December 10, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $225 copayment per day required for days 1-8. 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 inpatient hospital care from December 6, 2019 through December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physician's services to be provided.
You asked the Plan to pre-approve the physician's services. 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 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 services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve physician's services to be provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a left medial branch block (64493, 64494 and 64495).
You asked the Plan to pre-approve the medial branch block. You say that the medial branch blocks are medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says the Medicare guidelines for approval have not been met.
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 the medial branch block. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the member has radicular symptoms from her affected nerve roots and does not meet Medicare coverage criteria as listed in the LCD.
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 medial branch block have not been met. Therefore, we decided that the Plan does not have to pre-approve a left medial branch block (64493, 64494 and 64495).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for refraction (92015) Fitting of spectacles (92341) deluxe frames (V2020) and bifocal lenses (V2200) provided November 18, 2019.You asked the Plan to pay for the vision services. You say that the doctor does not know who he'll be seeing since he is assigned to the nursing facility and given a chart of patients in need of services so you are unable to obtain prior authorization.The Plan denied your request. The Plan says enrollee's must receive their vision services from an in-network provider. The provider is not a part of vendor network.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 these services when provided by an in-network optical provider We looked at the file and the Plan's rules. vision services provided by an out of network provider is not covered. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met.Therefore, we decided that the Plan does not have to pay forrefraction (92015) Fitting of spectacles (92341) deluxe frames (V2020) and bifocal lenses (V2200) provided November 18, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a myoelectric arm for the enrollee.
You asked the Plan to pre-approve the arm. You say that this is medically necessary. The Plan denied your request. The Plan says this type of prosthesis is considered experimental and investigational.
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 the arm. Our reviewer says that the requested arm is not considered medically reasonable and necessary in this case. Our physician reviewer found a below elbow prosthesis with myoelectronic control of terminal device is not medically necessary per the Social Security Act, Section 1862(a)1(A) as there is no evidence that an appropriately fitted standard body-powered prosthetic device can not be used or is insufficient to meet the functional needs of the enrollee in performing activities of daily living. Without prior use of a standard body powered prosthesis the request for a myoelectric below elbow prosthesis does not appeal to be furnished in a setting appropriate to the enrollee's medical needs and condition. 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 arm have not been met. Therefore, we decided that the Plan does not have to pre-approve a myoelectric arm for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids purchased October 8, 2019.
You asked the Plan to pay for the hearing aids. You say that you live in a retirement community and no longer drive and it is difficult for you to travel. This provider comes to the facility and you can get help for your hearing without difficulty. The Plan denied your request. The Plan says hearing aids must be ordered directly 
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 purchased directly. We looked at this physician's review, the file, and the Plan's rules. 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 the hearing aids purchased October 8, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services (97112, 97535, 97110, 97530) provided June 1 to July 31, 2018 
You asked the Plan to pay for the SNF services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was filed untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the SNF services was not filed until December 17, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for Skilled Nursing Facility (SNF) services (97112, 97535, 97110, 97530) provided June 1 to July 31, 2018
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for nail debridement provided on August 22, 2019.
You asked the Plan to pay for nail debridement. You say that there is authorization on file for all care. The Plan denied your request. The Plan says the provider is responsible for payment.
Medicare rules say that the provider, 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 nail debridement provided on August 22, 2019.