Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Brovana 15mcg/2ml solution (J7605).You asked the Plan to pre-approvethis medication. You say that you are requesting a reconsideration of the Plan's denial.The Plan denied your request. The Plan says the enrollee has not met the step therapy criteria for coverage of this medication.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 this medication. Our reviewer says that the enrollee does not meet the criteria for coverage of this medication. Our physician reviewer found that the enrollee is noted to have chronic obstructive pulmonary disease (COPD). A request has been made for the medication Brovana to treat the COPD. The health plan requires that the medication Perforomist be used. There is no evidence that the enrollee is allergic to or intolerant of Perforomist. There is no evidence that the enrollee has tried and not responded to Perforomist. There is no documentation as to why Perforomist would not be expected to be safe and effective for the enrollee. Therefore, We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage ofthis medication have not been met.Therefore, we decided that the Plan does not have to pre-approvethe Brovana 15mcg/2ml solution (J7605).the requested Brovana medication is not shown to be currently medically necessary and reasonable.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) provided.

You asked the Plan to pay for the subsequent nursing facility visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says this claim was notfiled timely.

The Plan follows Medicare rules. The rules say that claims for services furnished, must be filed no later than one calendar year after the date of service.

The record shows that a claim for the subsequent nursing facility visit was not filed until August 26, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility visit (99308) provided.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Chlorpromaz tablets.
You asked the Plan to pre-approve Chlorpromaz tablets. You say that you would like the Plan to reconsider
their denial. The Plan denied your request. The Plan says Chlorpromaz tablets are not covered under the
enrollee's Medicare Part B 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 Chlorpromaz tablets.
Benefits for Chlorpromaz tablets may be available under Medicare Part D. Contact the Plan that administers
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forphysician services (46930, 99213) provided on February 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that the service was medically necessary.The Plan denied your request. The Plan says there were network providers available.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 had network providers available who could have provided 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 forphysician services (46930, 99213) provided on February 24, 2020 by an out of network (OON) provider.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the enrollee needs to continue therapy at a SNF to regain his full independence before returning home.The Plan denied your request. The Plan says that the enrollee could be treated at a lower level of care.

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 based on the records provided, the enrollee qualifies for coverage of SNF care. Our physician reviewer found although the enrollee does not have documented skilled nursing needs, the enrollee does have documented skilled therapy needs. The enrollee appears to be functioning below his baseline.  There is no evidence that the enrollee has reached a plateau in function. Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted.Therefore, we decided that the Plan has to pre-approvevskilled nursing facility (SNF) care.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the back-up battery.
You asked the Plan to pre-approve the back-up battery. You say that you would like reconsideration because your current battery only lasts 4 hours. The Plan denied your request. The Plan says this is not covered because it is considered a convenience item.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that you have a battery for your portable concentrator, the requested back-up battery serves the same purpose as the battery for your concentrator. Therefore, we decided that the Plan does not have to pre-approve the back-up battery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery (11102) provided.

You asked the Plan to waive the copayment forthe outpatient surgery. You say that the services should not be considered a surgery and the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $350 copayment for Outpatient Surgical Services. 

You have been asked to pay a $215.04 co payment for the outpatient surgery. This is the allowable amount. The allowable amount is less than the $350 listed in the Evidence of Coverage for this type of 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 co payment for outpatient surgery (11102) provided.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 23, 2020 to June 27, 2020 by an out of network (OON) provider.You asked the Plan to pay forinpatient hospital care. You say that the attending physician ordered this admission based on the best interest of the enrollee.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.Medicarerules 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 had network providers available who could have provided 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 medical services provided on June 23, 2020 to June 27, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay foroutpatient mental health services provided on September 10, 2020 by an out of network (OON) provider.You asked the Plan to pay foroutpatient mental health services. You say that you would like this claim reprocessed and paid.The Plan denied your request. The Plan says there are in-network providers available for 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.The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 foroutpatient mental health services provided on September 10, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out of network (OON) provider.

You asked the Plan to pay for office visit. You say that you are appealing with supporting records.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and 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 had network providers available who could have provided 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 by an out of network (OON) provide
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for dental services (D4342, D9630, D2392) provided.

You asked the Plan to pay for the dental services. You say that the services should be covered.The Plan denied your request. The Plan says the services were rendered by an out-of-network provider and are not covered.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Dental services provided out-of-network are not covered under your dental plan.Therefore, we decided that the Plan does not have to pay for dental services (D4342, D9630, D2392) provided.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 24, 2020 by an out of network (OON) provider.You asked the Plan to pay forpractitioner visit. You say that your provider depends upon the facility staff to verify eligibility and obtain proper authorization.The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and authorization was not obtained.Medicare rules say that plans can requireenrollees 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 had network providers available who could have provided 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 medical services provided on August 24, 2020 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bone imaging whole body scan to be provided by an
out of network (OON) provider.
You asked the Plan to pre-approve a bone imaging whole body scan. You say that it is medically necessary for
the enrollee to receive a bone imaging whole body scan while out of the Plan's service area. The Plan denied
your request. The Plan says it is not medically necessary for the enrollee to receive a bone imaging whole body
scan while out of the Plan's service area. The Plan says there are in-network providers available to the enrollee
that can provide the requested service.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving
emergencies, out of area urgent care and care that cannot be provided by network providers.
The provider at issue in this case is not a network provider with the Plan. 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 bone imaging whole body scan. Our reviewer says that it is not medically
necessary for the enrollee to receive a bone imaging whole body scan while out of the Plan's service area. Our
physician reviewer found the enrollee is diagnosed with metastatic breast cancer. The requested bone scan in
this case can be deferred safely until the enrollee returns to the Plan's service area. The request is neither
emergent nor urgent.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a bone imaging whole body scan have not been met.
The Plan has network providers available who can provide the items/services at issue in this appeal. We found
no exception that would require the Plan to pre-approve a bone imaging whole body scan. Therefore, we
decided that the Plan does not have to pre-approve a bone imaging whole body scan to be provided by an out of
network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on July 29, 2020.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or
emergent, nor were they approved in advance.
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 did not pre-approve the
physician's services. 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 physician's services provided on July 29, 2020.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to waive or reimbursethe cost share for services provided on October 11, 2019.You asked the Plan to waive or reimbursefunds you believe were overpaid for services provided in 2019. You say that you believe you have overpaid the maximum out of pocket (MOOP) for 2019. The Plan denied your request. The Plan states that this copayment was applied based on the Plan contract agreement and the service provided. The Plan records and the explanation of benefits confirm the MOOP was not met at the time of service. 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 in 2019 there was a maximum out of pocket of $4500. The Plan has provided claim and payment information for each service in question. Both the records and the Explanation of Benefits (that you would also have a copy of)for each service clearly show the balance of the maximum out of pocket at the time of service. 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 or reimbursethe cost share for services provided on October 11, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay foran inpatient physician visit provided on August 4, 2019.You asked the Plan to pay forphysician visit. You say that you did not receive proper notice of the enrollee's benefit determination, hence the untimely submission of the claim.The Plan denied your request. The Plan says the denial of payment for this service is correct,because this claim was not submitted within the timely filing limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for physician visit was not filed until September 18, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to payforan inpatient physician visit provided on August 4, 2019
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance service provided on April 7, 2020.You asked the Plan to pay forthe ambulance service. You say that the Plan should pay this claim.The Plan denied your request. The Plan says the claim was not billed according to CMS billing guidelines.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services (A0429-QL) have not been met. Specifically, code A0429 is not the appropriate code for billing Medicare when the enrollee is pronounced dead after the ambulance is called. Medicare requires the reporting of A0428 for services provided under these circumstances.Therefore, we decided that the Plan does not have to pay forthe ambulance service provided on April 7, 2020
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered on April 11, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says the claim was not filed timely.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for these services was not filed until October 15, 2020. This means that more than one calendar year from the date of service had passed before a claim wasfiled.Therefore, we decided that the Plan does not have to pay forthe services rendered on April 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 30, 2020 by a
non-participating provider.
You asked the Plan to pay for these services. You say that the provider billed the wrong code. The Plan denied
your request. The Plan says the services were rendered by a non-participating provider without prior
authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided 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 September 30,
2020 by a non-participating provider.