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

We decided that the Plan does not have to pay for a screening prostate specific antigen (PSA) test provided on October 17, 2019.
You asked the Plan to pay for screening PSA test. You say that you are requesting that the Plan pay for this test. The Plan denied your request. The Plan says the denial of payment for this service is correct, because screening PSA tests are covered once every 12 months and you previously had a screening PSA test on May 30, 2019.
The Plan must follow Medicare rules. Medicare rules say that screening PSA tests are covered once every 12 months. We looked at the file and Medicare rules. A previous screening PSA test was performed for you on May 30, 2019; therefore 12 months had not passed before this test was performed. Based on this information, we decided that Medicare rules for coverage of screening PSA test have not been met. Therefore, we decided that the Plan does not have to pay for a screening prostate specific antigen (PSA) test provided on October 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe services provided to the enrollee on November 1, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysservices rendered by non-participating providers require prior authorization, as outlined in the 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 rendering 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 Plandoes not haveto pay forthe services provided to the enrollee on November 1, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the colonoscopy rendered to you on
September 24, 2019.
You asked the Plan to waive the copayment for these services. You say that this was your first colon screening
in over 10 years. The Plan denied your request. The Plan says the copayment was 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 $400
copayment for Medicare-covered outpatient hospital surgery services.
Review of the file shows that you received a diagnostic colonoscopy on September 24, 2019. The colonoscopy
was diagnostic and not screening in nature because it was performed due a history of colon polyps and benign
neoplasm of the colon. You have been asked to pay a $400 copayment for these services. These services fall
within the Medicare-covered outpatient hospital surgery 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 colonoscopy rendered to you on September 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from April 29, 2019 through May 3, 2019.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you instructed the ambulance to take you to the VA. 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 April 29, 2019 and discharged on May 3, 2019. You were asked to pay a $300 copayment per day from April 29, 2019 through May 2, 2019, days 1-4 of your inpatient hospital care. You were discharged on May 3, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $300 copayment per day required for days 1-6. The Plan also confirmed that Renown, nor the ambulance service, has records that the VA was on divert. The Plan reached out to the VA and confirmed that the VA will not agree to being billed as the Plan is your only payer. 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 April 29, 2019 through May 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM) for the enrollee.You asked the Plan to pre-approvethe requested device. You say that the enrollee will be able to monitor her sugars more frequently than the finger sticks.The Plan denied your request. The Plan says the enrollee is not treated with three or more insulin injections a day.The Plan follows Medicare rules. Medicare rules say that continuous glucose monitors are only covered under certain medical indications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determineif the Plan was correct in denying the request to pre-approve the requested device. Our physician reviewer found that the enrollee has a history of coronary artery disease and type 2 diabetes. The enrollee has only recently begun to check blood glucose levels 2 times a day. The criteria state that the enrollee must check blood glucose levels 4 times a day, and take 3 shots of insulin per day. The enrollee does not meet criteria as she is only taking 1 shot of insulin per day. Therefore, the services are not considered medically reasonable and necessary at this time. 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 requested device have not been met. Therefore, we decided that the Plan does not have to pre-approvea continuous glucose monitor (CGM) for the enrollee.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health services.You asked the Plan to pre-approve home health services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.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 home health services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee. The enrollee recently had skilled physical therapy services which were discontinued because the enrollee was unable to effectively participate in physical therapy. There is no documentation of any other need for skilled services. The requested services are not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met.Therefore, we decided that the Plan does not have to pre-approvehome health services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the specialist office visit provided on March 26, 2019.
You asked the Plan to waive the deductible for the specialist office visit. You say that you should not be responsible for this amount because you were not told the provider is out-of-network. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $500 deductible that applies towards out-of-network specialist visits. The specialist office visit you asked the Plan to waive the deductible for falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible that applies towards out-of-network specialist office visits. The record shows the provider is out-of-network.
This cost sharing is a contractual obligation that had not been met at the time the specialist office visit was received on March 26, 2019. Therefore, we decided that the Plan does not have to waive the deductible for the specialist office visit provided on March 26, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed above are met. Custodial care is 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or
therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria
for an inpatient basis in a skilled nursing facility setting.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services for the enrollee.
You asked the Plan to pre-approve the LTACH services. The Plan denied your request. The Plan says the enrollee's current needs are being met in the acute setting.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that in the case of this enrollee, following cervical fusion hardware revision surgery, acute blood loss resulted in requiring pressors and continued ventilation support. The progress notes state that although pressors were successfully weaned, continued mechanical ventilation, blood transfusion, and monitoring was needed. Recent notes describe significant neurological dysfunction, breathing on his own but requiring suctioning and Duo nebs, wounds requiring monitoring and dressing changes, plans for IVC filter and wound washout, and need for ongoing IV antibiotics. Current documentation suggests a need for ongoing acute care which is not likely to be required for more than 25 days based on the improvement thus far. The required therapy, wound care, and other acute care treatments can be managed safely and appropriately at the current facility. There are no services at the proposed LTACH that are not already available and being used at the current facility. Therefore, this request will be considered not medically necessary at this time. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drug injections provided from August 22, 2019 to October 1, 2019.
You asked the Plan to waive the coinsurance for Medicare Part B drug injections. You say that you disagree with the charges because the plan is allowing more than the provider billed. 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 20% coinsurance for Medicare Part B prescription drugs. You received Medicare Part B drug injections from August 22, 2019 to October 1, 2019. Therefore, you are responsible to pay your share of the cost-sharing charges. Please see the chart below.
Date of Service
Service
Allowed Amount
Amount You Owe
8/22/2019
Medicare Part B Drug
$6,039.30
$1,207.86
9/3/2019
Medicare Part B Drug
$6,039.30
$1,207.86
10/1/2019
Medicare Part B Drug
$6,039.30
$1,207.86
The total amount you owe is: $3,623.58.
You have been asked to pay the total coinsurance amount of $3,623.58 for Medicare Part B drug injections. Medicare Part B drug injections fall 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 Medicare Part B drug injections provided from August 22, 2019 to October 1, 2019.
We note your complaint that the plan is allowing more than the provider billed. Your complaint is a grievance that must be answered by the health plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that you are requesting reconsideration because you almost fell out of the tub and blood pressure went down and you had to go to the hospital. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from August 1, 2019 to August 15, 2019.You asked the Plan to pay for home health services. You say that these were medically necessary services.The Plan denied your request. The Plan says these services were not provided by a home health agency that participates in Medicare.The Plan must follow Medicare rules. Medicare rules say that home health services are covered when the home health agency that is providing the services to the beneficiary has in effect a valid agreement to participate in the Medicare program.We looked at the file and Medicare rules.The provider you received these services from does not participate in the Medicare program. Based on this information, we decided that Medicare rules for coverage of home health services have not been met.Therefore, we decided that the Plan does not have to pay for home health services provided from August 1, 2019 to August 15, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Novolog insulin injections.You asked the Plan to pre-approve the Novolog injections. You say that the requested medication is necessary.The Plan denied your request. The Plan says Medicare Part B does not cover self-injected drugs. This must be covered under a Part D 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-approve Novolog insulin injections.Benefits for the Novolog injections 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 pre-approve right lumbar radiofrequency ablation (RFA) services.
You asked the Plan to pre-approve the right lumbar RFA services. You say that the clinical information
provided supports the need for the service being requested. The Plan denied your request. The Plan says the
coverage limitations for the requested service have been met.
The Plan must follow Medicare rules. Medicare rules say that no more than 2 thermal RF sessions will be
reimbursed in any rolling 12-month year.
We looked at the file and Medicare rules. The records show that the enrollee received coverage for a right RFA
provided on April 22, 2019 and a left RFA on June 12, 2019. This means that 2 thermal RF sessions have
already been reimbursed within the last 12 months, and the benefit limitation for thermal RF sessions is current
exhausted. Based on this information, we decided that Medicare rules for coverage of the right lumbar RFA
services have not been met. Therefore, we decided that the Plan does not have to pre-approve right lumbar
radiofrequency ablation (RFA) services.
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 September 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.
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 September 4, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe x-ray services (73030, 73070) provided on June 18, 2019.You asked the Plan to pay forthe x-rays. You say that the services were medically necessary.The Plan denied your request. The Plan says the records do not show the services were emergent. There were in-network providers available that could provide 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.Therequested 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 x-ray services (73030, 73070) provided on June 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to the enrollee on February 20, 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 procedure code G0483 is not supported.
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 G0483 is definitive drug testing, 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation does not contain testing results of 22 or more drug classes. 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 the enrollee on February 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Belbuca (buprenorphine) buccal film.
You asked the Plan to pre-approve the Belbuca film. You say that this is a medically necessary treatment. The Plan denied your request. The Plan says this self-administered oral medication is not covered by Medicare Part B.
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 Belbuca (buprenorphine) buccal film.
Benefits for the Belbuca film 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Prolia.You asked the Plan to pre-approveProlia. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Zoledronic Acid or a history of osteoporotic fracture before it will authorize Prolia.Medicare covers Part B medications when they are reasonable and necessary butallows 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 enrollee does not meet the Medicare criteria for a step therapy exception for Prolia. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Zoledronic Acid. The record does not show that Zoledronic Acid would likely be less effective and/or have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Basedon 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-approveuse of Prolia.