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

We decided that the Plan does not have to waive the copayment for the CT scan provided by on July 26, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you were informed the results were inconclusive and you needed another scan. You say that you do not have money to spend on an inconclusive test. 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 $50 copayment for high-tech radiology services. Covered services include MRIs/MRAs, nuclear cardiology services, CT or PET Scans. You have been asked to pay a $50 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The records show that the CT scan was performed. 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 CT scan provided by on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora domiciliary or rest home visit for the evaluation and management of an established patient (99337) provided on August 22, 2019.You asked the Plan to pay fora domiciliary or rest home visit for the evaluation and management of an established patient. physicians and/or nurse practitioners be called in to see the patient as an attending provider in an outpatient capacity. You request the HealthPlantoreview the medical records for payment consideration.The Plan denied your request. The Plan says the enrollee received physician services. It was verified that the physician is a non-contracted provider. A review of the enrollee's account shows she does not have a valid referral on file for theservice in question. The Health Plan does not deny the medical necessity of the services however, authorization was not obtained. In addition, the enrollee's 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-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 fora domiciliary or rest home visit for the evaluation and management of an established patient (99337) provided on August 22, 2019 by out of network provider.
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 Contour Next Test Strips. You say that the enrollee needs Contour Next Test Strips. The Plan denied your request. The Plan says there is no clinical information to show medical necessity for the non-preferred brand of 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 medical reason in the record why Contour Next Test Strips are necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for coverage of Contour Next Test Strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Contour Next Test Strips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysit would not be appropriate to transfer you to a lower level of care if ongoing acute level care is required.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level in an IRF.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituximab (J9312).
You asked the Plan to pre-approve the Rituximab. You say that the Rituximab is medically necessary. The Plan denied your request. The Plan says the records do not support the medical necessity for a step therapy exception.
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 the Rituximab. Our reviewer says that you have not tried and failed a trial of Inflectra, Remicade or Simponi Aria. Our physician reviewer found the documentation does not support that the Plan's required drugs would likely be less effective, and/or would likely have an adverse effect. 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 Rituximab have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituximab (J9312).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveamitriptyline tablets.You asked the Plan to pre-approveamitriptyline tablets. You say that this medication would help the enrollee sleep and control her pain.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's Part D prescription drug 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 pre-approveamitriptyline tablets.Benefits for amitriptyline tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (CPT Code 99308) provided to the enrollee on March 16, 2018, by an out-of-network provider.
You asked the Plan to pay for the services. You say that the provider is not aware of the patient insurance when he sees the patient. The Plan denied your request. The Plan says the member does not have out-of-network benefits.
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 subsequent nursing facility care (CPT Code 99308) provided to the enrollee on March 16, 2018, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the urgent care visit provided on August 6,
2019.
You asked the Plan to waive the copayment for the urgent care visit. You say that you went to urgent care
because the doctor's office didn't get back to you. You say that the Plan should pay the bill. 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 $45 for
each Medicare-covered urgent care provider visit.
You have been asked to pay a $45 copayment for the urgent care visit. The urgent care visit falls within the
"Urgently needed services" 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 urgent
care visit provided on August 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from August 9, 2019 to October 28, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plandenied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from August 9, 2019 to October 28, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from August 20,
2019 through August 24, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were charged for waiting
for an MRI. You say that you should not have to pay for the extra days. 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 $295
copayment per day for days 1-5 for each in-network Medicare-covered stay. The day before you are discharged
is your last inpatient day.
You have been asked to pay a $1,180 copayment for the inpatient stay. ($295/day x 4 days = $1,180). The
inpatient stay falls within the "Inpatient hospital 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 inpatient stay provided from August 20, 2019 through August 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to paythe glucose monitor, test strips, lancets, control solution, and lancet device provided from July 30, 2019 to October 18, 2019.You asked the Plan to paythe glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have thetracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to paythe glucose monitor, test strips, lancets, control solution, and lancet device provided from July 30, 2019 to October 18, 2019
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on August 2, 2019.
You asked the Plan to waive the copayment for the CT scan. You say that you are part of a lung study. You say
that you should not be charged for exams. 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 $200
copayment after the deductible is met for each advanced imaging service.
You have been asked to pay $92.30, which is less than the standard $200 copayment for the CT scan. The CT
scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The
CT scan is considered diagnostic imaging. 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 CT scan
provided on August 2, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forhearing aids providedon July 24, 2019.You asked the Plan to reimburse you forthe hearing aids.The Plan denied your request. The Plan says you must use a Hearing Care Solutionsprovider to provide covered hearing aids.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 you use a Hearing Care Solutions provider.We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the Plan. 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 reimburse you forthe hearing aids providedon July 24, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for segmental pneumatic appliance for use with pneumatic compressor, half leg (CPT Code E0669) and pneumatic compressor, segmental home model with calibrated gradient pressure (CPT Code E0652) provided on July 16, 2019.
You asked the Plan to waive the coinsurance for the DME. You say that a representative from the supplier advised you that due to your low income you should not have to pay for the equipment. 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 show that you received DME provided on July 16, 2019. You are asked to pay 20% coinsurance for the DME. 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 segmental pneumatic appliance for use with pneumatic compressor, half leg (CPT Code E0669) and pneumatic compressor, segmental home model with calibrated gradient pressure (CPT Code E0652) provided on July 16, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for thrombolytic venous therapy (37212-78) provided on February 25, 2019 by the physician.
You asked the Plan to pay for thrombolytic venous therapy. You say that the service was provided and payment should be rendered. The Plan denied your request. The Plan says based on the documentation provided, the claim was processed correctly.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 37212 is thrombolytic venous therapy. We asked our Maximus coding 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 thrombolytic venous therapy. Our reviewer says that the service is not supported by the medical records. Our coding reviewer found CPT code 37212 is not supported. The medical record does not contain evidence that a continuous infusion of a thrombolytic to treat a clot was performed. According to CPT rules, a thrombolytic injection as part of a thrombectomy procedure is not separately reportable. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of thrombolytic venous therapy have not been met. Therefore, we decided that the Plan does not have to pay for thrombolytic venous therapy (37212-78) provided on February 25, 2019 by the physician.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forassembly and operation of pump with oxygenator or heat exchanger (withor without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided to the enrollee on August 12, 2019.You asked the Plan to pay forthe services. You say that these charges are for the perfusionist that setup and operated the heart-lung machine for this patients surgery. You state the CPT code 99190 is for the setup and operation of the Heart Lung machine for the above patients open heart surgery and it takes a half hour to an hour to set up the Heart Lung Machine. You state the perfusionist is required to be in the operating room during the length of the procedure and per hospital protocol it is mandatory that the surgeon, anesthesiologist and perfusionist transport the patient to the unit and be there until the patient is stable.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. These services and CPT codes are statutorily excluded by Medicare. Medicare does not pay any provider or supplier other than the hospital for services furnished to the beneficiary while an inpatient in hospital, and this takes precedence over the claim system denial. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made between the facility and outside vendors. The enrollee received the services in the facility during inpatient hospitalization, and payment for this service would be included in the part-A DRG payment to the facility. Payment for this service is the responsibility of the facility to any vendor.Any and all codes on this claim are denied, and in addition, previous payments to these providers for this member are subject to recoupment.Therefore, we decided that the Plan does not have to pay forassembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided to the enrollee on August 12, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay fornon-emergent ambulance services provided to the enrollee on June 18, 2019.You asked the Plan to pay fornon-emergent ambulance services. You say that the claim should be paid.The Plan denied your request. The Plan says the services were rendered without an authorization.Medicare rulessay 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 fornon-emergent ambulance services provided to the enrollee on June 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on July 3, 2018 and
billed under code 0005U.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your
request. The Plan says code 0005U is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered. Medicare specifically states code 0005U is not covered. Therefore, we decided that
the Plan does not have to pay for lab services provided to the enrollee on July 3, 2018 and billed under code
0005U.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a health club membership.
You asked the Plan to pre-approve the health club membership. You say that you would like to increase stamina, strengthen your back and be able to walk more on your own. The Plan denied your request. The Plan says your Plan does not cover a fitness program or health club membership.
The Plan must follow Medicare rules. The rules say that Medicare does not cover gym benefits. The services at issue in this appeal are gym benefits. Your Plan does not cover a fitness program or health club membership. Therefore, we decided that the Plan does not have to pre-approve a health club membership.