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

We decided that the Plan does not have to pre-approvea CT Scan of the thorax (71250).You asked the Plan to pre-approvethe CT Scan. You say that you would like reconsideration because the CT Scan is medically necessary.The Plan denied your request. The Plan says it has not been at least 12 months since the last study.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 wascorrect in denying the request to pre-approve the CT Scan. Our reviewer says that a repeat CT Scan at 6 months is not medically reasonable and necessary. Our physician reviewer found 12 month follow-ups are generally recommended for nodules less than 6mm.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-approvea CT Scan ofthe thorax (71250)
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve RELPAX for the enrollee.You asked the Plan to pre-approve this drug. You say that the enrollee relies on this for migraine relief. The Plan denied your request. The Plan says that this is not covered under 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 RELPAX for the enrollee.Benefits for this drug maybe available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on January 13, 2020 by an out of network (OON) provider. You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 laboratory services provided on January 13, 2020 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe non-emergent ambulance service provided on October 10, 2019 by an out of network provider.You asked the Plan to pay forthe non-emergent ambulance service. You say that the transport was medically necessary.The Plan denied your request. The Plan says you didnot request 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 providersavailable who can provide the services at issue in this appeal. The Plan did not pre-approve the service 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 forthe non-emergent ambulance service provided on October 10, 2019 by an out of network provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for medical services (74283, 99199) provided on February 12, 2019.
You asked the Plan to pay for medical services. You say that these services were medically necessary. The Plan denied your request. The Plan says coverage of these services is the responsibility of Original Medicare.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on February 6, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for medical services (74283, 99199) provided on February 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enoxaparin (J1650). You asked the Plan to pre-approve Enoxaparin. You say that this is medically necessary.The Plan denied your request. The Plan says coverage of this medication is the responsibility of the enrollee's 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-approve Enoxaparin (J1650). Benefits for Enoxaparin 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from December 4, 2019 through December 7, 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 4, 2019 and discharged on December 7, 2019. You were asked to pay a $150 copayment per day from December 4, 2019 through December 6, 2019, days 1-3 of your inpatient hospital care. You were discharged on December 7, 2019 and there was no copayment charge for the day of discharge. Per your contract there is a $150 copayment per day required for days 1-3. 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 4, 2019 through December 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the antigen therapy services rendered on July 26, 2019 to October 10, 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 95165 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 95165 is professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses). We find that CPT code 95165 is not supported in the medical record. Specifically, there is no documentation of a valid allergy extract prescription and mixing log to validate the billed services. 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 antigen therapy services rendered on July 26, 2019 to October 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF admission. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested admission is not medically necessary.
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 admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee does not have complex wound care, a need for IV antibiotics, new enteral feedings. The enrollee was dependent for bed to chair transfers, sitting to laying down, and for picking up objects. The documentation does not support that the enrollee requires the specialized skills, knowledge, or judgment of a skilled professional nurse or qualified therapist to safely and effectively provide medically necessary and reasonable treatment. The documentation does not support that skilled nursing or skilled therapy services are required on a daily basis. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, at a SNF level of care.
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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the documentation and clinical information provided supports the request for LTACH care. The Plan denied your request. The Plan says the enrollee transfers interdependently and is stand-by-assist for mobility related activities of daily living. The Plan says that LTACH care is not medically necessary and that skilled nursing facility care or discharge home with support would be more appropriate.
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 reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an acute care hospital (ACH) for an airway obstruction determined to be cancer. The enrollee received a tracheotomy and is not on a ventilator. There is no evidence that the enrollee requires services that are not currently available. There is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such a time that no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prevention Genetics Dementia Panel testing.
You asked the Plan to pre-approve these services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has cognitive decline,
dysarthria, pseudobulbar affect, and ataxia. Neurocognitive testing has demonstrated progressive cognitive
decline. Her symptoms are believed to be most consistent with frontotemporal dementia and similar conditions.
The documentation does not support that the Prevention Genetics Dementia Panel is medically reasonable and
necessary for the enrollee in this case. Genetic testing for subtypes of dementia does not definitively rule in or
rule out a particular diagnosis, and there is potential for both false positive and false negative results. Clinical
management is generally based on clinical parameters, rather than on the results of genetic testing. Testing
which does not have a proven relation to the management of a medical diagnosis for the health of an enrollee is
not a covered Medicare benefit.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve Prevention Genetics Dementia Panel testing.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the physician visit provided on January 22, 2020.
You asked the Plan to waive the deductible for the physician visit. The Plan denied your request. The Plan says that you had not yet met your deductible for the year.
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 for covered medical services. The item or service you asked the Plan to waive the deductible for falls within the benefit category of covered medical services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible for covered medical services. This cost sharing is a contractual obligation that had not been met at the time the physician visit was received on January 22, 2020. Therefore, we decided that the Plan does not have to waive the deductible for the physician visit provided on January 22, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe specialist services rendered on February 18, 2020 and March 6, 2020.You asked the Plan to waive the copayments forthese services. You say that you saw a nurse practitioner and should only have a $5 copayment per visit.The Plan denied your request. The Plan says the copayments were 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 $40 copayment per specialist office visit. Review of the file shows that you received specialist services on February 18, 2020 and March 6, 2020. You have been asked to pay a $40 copayment per visit for these services, for a total of $80. These services fall within the per specialist office visit benefit category. This copayment applies regardless of whether you see a physician or a nurse practitioner. 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 copayments forthe specialist services renderedon February 18, 2020 and March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block injection.
You asked the Plan to pre-approve these services. You say that you have constant pain. The Plan denied your request. The Plan says the services are not medically necessary.
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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the records show that you have a history of right knee pain and had a total knee replacement. You have continued pain that has not responded to medical therapy with pain medication, physical therapy, and steroid injections. The requested genicular nerve block is considered investigational in nature for the treatment of chronic knee pain. The services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block injection.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ensure oral supplements for the enrollee.You asked the Plan to pre-approve Ensure. You say that Ensure is medically necessary for the enrollee.The Plan denied your request. The Plan says Ensure is not covered by Medicare.The Plan must follow Medicare rules. The rules say that Medicare does not pay for nutritional supplementation.Ensure and similar products are oral nutritional supplements which are not covered by Medicare. Therefore, we decided that the Plan does not have to pre-approve Ensure oral supplements for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost sharing for the services rendered from February 4, 2020 to February 7, 2020.You asked the Plan to waive the cost sharing for these services. You say that you disagree with the charges.The Plan denied your request. The Plan says the cost sharing 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 $40 copayment per visit to a specialist, a 20% coinsurance for durable medical equipment and related supplies, a $50 copayment for x-rays, a 20% coinsurance for Medicare Part B prescription drugs, and a$150 copayment for MRI.Review of the file shows that you received specialist services on February 4, 2020. You have been asked to pay a $40 copayment for these services. These services fall within the visit to a specialist 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. The file shows that you received a lumbar-sacral orthosis (LSO) on February 4, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $205.69. These services fall within the durable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.The file shows that you received an x-ray of the lumbar spine on February 4, 2020. Per your contract with the Plan, there is a $50 copayment for x-rays. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $10. Given that the allowed amount was less than the $50 copayment, you have been asked to pay $10 for these services.The file shows that you received a triamcinolone acetonide injection on February 4, 2020. You have been asked to pay a 20% coinsurance for these services, for a total of $1.25. These services 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.The file shows that you received an MRI of the lumbar spine on February 7, 2020. Per your contract with the Plan, there is a $150 copayment for MRIs. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $132.47. Given that the allowed amount was less than the $150 copayment, you have been asked to pay $132.47 for these services.Therefore, we decided that the Plan does not have to waive the cost sharing for the services rendered from February 4, 2020 to February 7, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zioptan.You asked the Plan to pre-approve Zioptan. You say that the enrollee has had adverse reactions to other agents and needs to have the Zioptan brand for adequate treatment.The Plan denied your request. The Plan says this drug is not covered for the enrollee's condition 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 Zioptan.Benefits for Zioptan 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the CT scan provided on February 7, 2020.
You asked the Plan to waive the copayment for the CT scan. You say that this procedure should be covered. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $180 copayment for advanced imaging services at an in-network PCP's office, specialist's office or freestanding radiological facility. You have been asked to pay a $180 copayment for the CT scan. The CT scan falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows that a CT scan is considered an advanced imaging service.
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 February 7, 2020.