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

We decided that the Plan does not have to pre-approve Simponi pen injection.
You asked the Plan to pre-approve Simponi pen injection. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug is not a covered 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 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 Simponi pen injection.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient surgical services provided on August 22, 2019 by the out of network provider.You asked the Plan to pay forthe outpatient surgical services. You say that the enrollee presented to the emergency room initially and the services were provided in good faith.The Plandenied your request. The Plan says the services at issue were not emergent and were not preauthorized. The plan has in-network providers that could render the services at issue.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 providerwith 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 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 foroutpatient surgical services provided on August 22, 2019 by the out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on September 6, 2019.
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 the enrollee did not have prior authorization and the ordering provider was not a plan contract provider.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for lab services provided to the enrollee on September 6, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for vision care provided on September 30, 2019 by an in-network provider.
You asked the Plan to waive the copayment for vision care. You say that you should not be liable for the cost share due to not being aware it was not a covered service. 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). You were seen in the office for yearly exam for cataracts and was scheduled for a medical eye exam. You received a non-routine eye exam on September 30, 2019. You are asked to pay a $35 copayment for the specialist visit. 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 vision care provided on September 30, 2019 by an in-network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve gradient compression garment identified with code
A6549.
You asked the Plan to pre-approve the compression garment. You say that you suffer from lymphedema in
your breast. The Plan denied your request. The Plan says the item does not meet the definition of a surgical
dressing.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are
non-covered because they do not meet the statutory definition of a surgical dressing.
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve gradient
compression garment identified with code A6549.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for definitive drug testing (G0482) provided to the enrollee.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your
request. The Plan says the enrollee did not have prior authorization and no medical records were submitted to
show this testing was medically necessary or met the Medicare coverage criteria for this type of testing.
The Plan must follow Medicare rules. Medicare rules say that plans can require enrollees to get care from
network providers. Medicare has specific coverage criteria for definitive drug testing. The contract with the
Plan says that the Plan must 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.
The Plan did not pre-approve this testing. The physicians order and the medical records must specifically show
how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed
to this testing being done for screening purposes. We found no exception that would require the Plan to pay for
this service. Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0482)
provided to the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forwound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories (CPT Code A6550) provided to the enrollee on August 16, 2019.You asked the Plan to pay forthe wound care set. You say that you had billed A7000 and A6500 for Total amount of $700.00 and the Plan denied A6550 stating that procedure code A6550 does not meet medical necessity, but you found that for previous date of service July 11, 2019 or A6550 insurance had paid the claim.The Plan denied your request. The Plan says the Medicare rules have not been met.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the wound care set. Our physician reviewer found records note the wound has increased without evidence of healing since the last evaluation. As such, criteria are not met and medical necessity is not determined.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 wound care set have not been met.Therefore, we decided that the Plan does not have to pay forwound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories (CPT Code A6550) provided to the enrollee on August 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea spine procedure (22869, 77003).You asked the Plan to pre-approvea spine procedure. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has 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 a spine procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in thiscase. Our physician reviewer found the device is experimental. More research is needed to show safety and efficacy.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverageof a spine procedure have not been met.Therefore, we decided that the Plan does not have to pre-approvea spine procedure (22869, 77003).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on August 20, 2019.
You asked the Plan to pay for the orthosis. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says they were unable to discover any evidence of an established relationship between the member and the ordering physician. The Plan states there were no claims submitted for an evaluation and management service. The Plan states the review of claims history for this member, and a review of the submitted documentation does not contain evidence of a prior Telemedicine or Telehealth service with the ordering physician as required per CMS guidelines.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the orthosis. Our reviewer says that the enrollee does not meet criteria for the orthosis ordered. Our physician reviewer found the documentation in the case file does not support that the requested shoulder/arm orthosis was medically reasonable and necessary for the enrollee in this case. A physical examination of the shoulder would reasonably be required to adequately assess whether the shoulder/arm orthosis was medically necessary for an enrollee. The documentation does not support that the orthosis was medically reasonable and necessary for the enrollee in this case, as there is no documentation of a credible physical examination of the shoulder. 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 orthosis have not been met. Therefore, we decided that the Plan does not have to pay for shoulder elbow wrist hand orthosis (L3960) provided to the enrollee on August 20, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 18, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that this was a colonoscopy screening and you disagree with the charges. 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 a $200 copayment for surgery services provided at an ambulatory surgical center. The medical records show that you had polyps removed during a colonoscopy on May 18, 2019. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $200 copayment. You have been asked to pay a $200 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers 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 a colonoscopy provided on May 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on October 10, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that you were forced to go to the hospital. You say that the copayment should be waived. 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 $90 copayment per emergency room visit within or outside the service area. You have been asked to pay a $90 copayment for the ED visit. The ED 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 the ED visit provided on October 10, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 16, 2018 to January 31, 2019 by out of an network provider.
You asked the Plan to pay for practitioner visits. You say that there were no other providers available to treat the enrollee, and the Plan must cover Medicare-covered benefits. The Plan denied your request. The Plan says the denial of payment for these services 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 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 July 16, 2018 to January 31, 2019 by an out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance ride provided on September
6, 2019.
You asked the Plan to waive the copayment for the ambulance ride. You say that you were told you would not
be responsible for a copayment since you were transported between two hospitals. 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 $325
copayment for each Medicare-covered one-way ambulance trip.
You have been asked to pay a $325 copayment for the ambulance ride. The ambulance ride falls within
"Ambulance 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
ambulance ride provided on September 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services (99309) provided on June 14, 2019 by out of network provider.You asked the Plan to pay for the physician services. You say that the services should be covered.The Plan denied your request. The Plan says the services were provided out-of-network and were not emergent or preauthorized.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 (99309) provided on June 14, 2019 by out of network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent transportation services (A0425, A0428 and A4670) provided on September 30, 2019.
You asked the Plan to pay for the non-emergent transportation services. You say that you would like reconsideration as it was medically necessary for the member to be moved by stretcher. The Plan denied your request. The Plan says ambulance transport to an outpatient physician office is not a Medicare covered destination.
The Plan must follow Medicare rules. The rules say that Medicare pays for ambulance transports only when they meet certain origin and destination requirements. A doctor's office is not a covered destination. The services you have asked the Plan to pay for are ambulance transport services to a doctor's office. Therefore, we decided that the Plan does not have to pay for non-emergent transportation services (A0425, A0428 and A4670) provided on September 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204), and drug testing (G0483) provided on March 14, 2019 by an out of network provider. You asked the Plan to pay for an office visit and drug testing. You say that the member gave you the incorrect primary insurance initially. She gave Medicare as her primary insurance. It wasn't until after the denial that you found out the patient was active with another health plan. This is why authorization was not obtained prior to rendering services. You are requesting review of documentation and reconsideration of the claim for reimbursement. The Plan denied your request. The Plan says that this doctor is a non-network provider who does not work with the member's health plan. The member self-directed for care. The member's primary care provider did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 an office visit (99204), and drug testing (G0483) provided on March 14, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
You asked the Plan to preapprove a pneumatic compression device. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services
You asked the Plan to pre-approve the LTACH services. You say that the enrollee requires wound management, pain management, and lab monitoring. The Plan denied your request. The Plan says the enrollee's needs are being met in the current 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 the enrollee is currently undergoing treatment at an acute care hospital (ACH) for complications following recent coronary bypass surgery. The enrollee experienced bleeding from a groin wound and suffered a cardiac arrest. She eventually received a right leg amputation and is receiving wound care. The enrollee is not intubated/ventilated. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to approvecontinued skilled nursing facility (SNF) services beyond January 9, 2020.You asked the Plan to approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says you have exhausted the benefit limit.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that you received 100 days of SNF care during the benefit period from October 2, 2019 to January 9, 2020. The Plan has covered 100 days of SNF care.Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days ina row.Therefore, we decided that the Plan does not have to approvecontinued skilled nursing facility (SNF) services beyond January 9, 2020