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

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided from September 28,
2019 to October 5, 2019.
You asked the Plan to pay for home infusion therapy. You say that this is a valid code. The Plan denied your
request. The Plan says this code is not valid for Medicare purposes.
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 find that CPT code S9328 is not supported in the medical record. Specifically, this code has a status
indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this
information, we decided that Medicare rules for coverage of home infusion therapy have not been met.
Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided from
September 28, 2019 to October 5, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the non-emergency transportation services to be provided by an out of network (OON) provider.You asked the Plan to pre-approve the non-emergency transportation services.You say that there was an issue with the network transportation provider not showing up to pick you back up from the doctor's office and your family is paying out of pocket for reliable transportation.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider. The plan says that non-emergent services with non-contracted providers require prior-authorization prior to services being rendered.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 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approve the non-emergency transportation services to be provided by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the chest x-ray provided on November 13, 2019.
You asked the Plan to waive the copayment for the chest x-ray. You say that you want to know why the Plan
didn't pay anything. 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 for basic radiological services at an in-network outpatient hospital.
You have been asked to pay $58.22, which is less than the standard $90 copayment for the chest x-ray. The
chest x-ray falls within the "Outpatient diagnostic tests and therapeutic services and 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. Therefore, we decided that
the Plan does not have to waive the copayment for the chest x-ray provided on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services that you provided on June 29, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says that the 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 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 physician's services that you provided on June 29, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to provide a continuous glucose monitor (CGM).You asked the Plan to provide the CGM. You say that the CGM is medically necessary.The Plan denied your request. The Plan says that rules for coverage have not been met.The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only when they are medically reasonable and necessary and replace a blood glucose monitor.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 provide the CGM. Our reviewer says that the CGM is medically necessary. Our physician reviewer found the enrollee checks his blood glucose daily and is on insulin. The Enrollee is unable to use a traditional glucometer due to a tremor. A CGM is medically appropriate in this case.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 CGM have been met.Therefore, we decided that the Plan has to providea continuous glucose monitor (CGM).If the Plan does not agree with ourdecision,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 again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the medical services to be provided by an out of network (OON) provider.You asked the Plan to pre-approveneurosurgery visit. You say that the enrollee has been under your care since having surgery, and the enrollee needs treatment.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network neurosurgeon.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 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvethe medical services to be provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on October 9, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition or medical records; therefore the billed code cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on October 9, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics for the enrollee.
You asked the Plan to pre-approve foot orthotics. You say that these are medically necessary for the enrollee. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that the enrollee does not suffer from diabetic foot disease and does not wear a leg brace. Although orthotics may be appropriate for the enrollee, neither Medicare nor the Plan provides coverage of orthotics for the enrollee's condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.You asked the Plan to pre-approvethe compression stockings. You say that you require these compression garments.The Plan denied your request. The Plan says the enrollee does not have any qualifying wounds.The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6549 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound.The record doesnot show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare.Therefore, we decided that the Plan does not have to pre-approvecompression stockings identified with code A6549.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided September 9 to September 12, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient services were medically necessary. The Plan denied your request. The Plan says that coverage criteria have not been met.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided September 9 to September 12, 2019.
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 again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Rituximab injections (J9312) of 375 mg in weekly intervals of 4 weeks.You asked the Plan to pre-approvethe Rituximab injections. You say that these injections have been well established as an effective treatment for the enrollee's condition.The Plan denied your request. The Plan says the Rituximab injections of 375 mg in weekly intervals of 4 weeks are not medically necessary.The Plan also says that the requirements support the use of Rituximab when the maintenance dose is no more than 500 mg given every 6 months.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Rituximab injections. Our reviewer says that the weekly Rituximabinjections of 375 mg each are not medically reasonable and necessary for the enrollee.Our physician reviewer found the documentation does not support that the injection dosage amount and frequency is safe and effective for the enrollee. Our reviewer found that fixed interval dosing with Rituximab, either 500 mg or 1000 mg administered every 6 months for a period of 2 years is recommended. Our physician reviewer also found that Rituximab 500-1000 mg every 6-12 months for up to 5 years could be considered.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Rituximab injections have not been met. Therefore, we decided that the Plan does not have to pre-approve the Rituximab injections (J9312) of 375 mg in weekly intervals of 4 weeks.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out of network oncology consultation.
You asked the Plan to pre-approve the requested provider. You say you were initially approved for biopsy for an ENT specialist at the same facility due to this service not being available in network at the time of request. You state you have received care since then. The Plan denied your request. The Plan says your contract requires you to receive care from providers who are part of your primary care physician's (PCP) specialty network. The Plan says that your medical group referred you to this provider to see the surgeon there for specialized care. The records show the surgeon performed a biopsy but is not planning to do surgery at this point. The Plan states you have now been referred to second oncologist. The Plan states that since you have not yet started your care with the radiation oncologist, and this treatment is available in network, it is reasonable for you to see an oncologist through your contracted medical group.
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 requested provider is not a network provider with the Plan. The Plan has provided you with the name of the medical group in network that can provide treatment. At this time, we found no exception that would require the Plan to pre-approve this request. Therefore, we decided that the Plan does not have to pre-approve an out of network oncology consultation.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oxycontin tablets.You asked the Plan to pre-approveself-administered drugs. You say that the enrollee needs this medication.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.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-approveoxycontin tablets.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 16, 2019.You asked the Plan to waive the copayment for the ambulance transport. You say that there is no control over who answers a 911 call. You say that the charge is excessive.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 $250 copayment for each one-way ground travel trip.You have been asked to pay a $250 copayment for the ambulance transport. The ambulance transport falls within the "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 transport provided on September 16, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient clinic visits provided from October 17, 2019 through November 7, 2019.
You asked the Plan to waive the copayment for the outpatient clinic visits. You say that the ongoing issues were not resolved. You say that you are disputing the charges. The Plan denied your request. The Plan says the copayments 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 $35 copayment for specialist services. You have been asked to pay a $35 copayment for each outpatient clinic visit. The total amount you owe is $140 ($35/visit x 4 visits = $140). The outpatient clinic visits fall within the "Physician/Practitioner services, including doctor's office visits" 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 outpatient clinic visits provided from October 17, 2019 through November 7, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Buprenorphine Patch.
You asked the Plan to pre-approve the Buprenorphine Patch. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the Buprenorphine Patch is intended for patient self-administration and is not covered under 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 a Buprenorphine Patch.
Benefits for the Buprenorphine Patch 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 for podiatry services provided on May 7, 2019 by an out of network (OON) provider.You asked the Plan to pay for podiatry services. You say that the member's skilled nursing facility is responsible for obtained prior authorization, not you.The Plan denied your request. The Plan says no prior authorization was 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 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 podiatry services provided on May 7, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the pneumatic compressor and appliances to be provided by an out of network provider.
You asked the Plan to pre-approve the pneumatic compressor (E0651) and appliances (E0667). You say that you are the only suppliers for this prescribed pump. The Plan denied your request. The Plan says Medicare considers all pneumatic compressor devices therapeutically equivalent by virtue of uniform treatment by the Contractor for Pricing, Data Analysis and Coding (PDAC).
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 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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the pneumatic compressor and appliances to be provided by an out of network provider.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay forthe dental bleaching (D9974) provided on November 18, 2019.You asked the Plan to pay forthe dental bleaching. You say that the services that you received should be covered. You say that they were routine care. You also say that you did get fillings but the provider advised to let your plan pay beforethey bill you.The Plan denied your request. The Plan says that dental bleaching is not listed as a covered service.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather andforward to the IRE information regarding its decision to deny coverage or payment.The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. the Plan did not provide a copy of the applicable Evidence of Coverage for this case. We asked for this document but it was not provided to us. Without this information we cannot determine that the Plan's coverage rules support the denial of payment in this case, or that the enrollee has been adequately notified of the Plan's coverage rules and benefits. Therefore the Plan has not substantiated their denial of payment in this case.Therefore, we decided that the Plan has to pay forthe dental bleaching (D9974) provided on November 18, 2019.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 again, we will send you a letter.