Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forhearing services provided on October 30, 2019.You asked the Plan to waive the copayment forhearing services. You say that 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 $40 copayment for hearing services. You have been asked to pay a $40 copayment for hearing services. Hearing services fallwithin the hearing 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 forhearing services provided on October 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an alpha-2-macroglobulin injection to treat osteoarthritis.You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the requested injection to treat osteoarthritis is experimental and not accepted by the medical community.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 the requested services. Our physician reviewer found that you are experiencing left shoulder pain with evidence of advanced joint degeneration on imaging studies.  Alpha-2-macroglobulin injections for arthritis are experimental and investigational. The documentation does not support that the injection is medically reasonable and necessary. The documentation does not support that the injection is safe and effective.We looked at this physician's review,the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve an alpha-2-macroglobulin injection to treat osteoarthritis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 10, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitoring system.
You asked the Plan to pre-approve a continuous glucose monitoring system. You say that you meet criteria for a Dexcom G6 continuous glucose monitoring system. The Plan denied your request. The Plan says you are not insulin injecting three or more times a day.
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 looked at the file and Medicare rules. The record shows you are not insulin treated three or more times a day or testing four or more times a day. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitoring system have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitoring system.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approveComputed Tomography (CT) of the Abdomen and Pelvis (74177).You asked the Plan to pre-approvethe CT scan. You say that the CT scan 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 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 was correct in denying the request to pre-approve the CT scan. Our reviewer says that coverage criteria has been met. Our physician reviewer found A CT scan that involves the abdomen and pelvis is necessary to fully evaluate the extent of disease which is known to involve the liver. A CT chest does not fully evaluate the liver.We looked at this physician's review, thefile, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the CT scan have been met.Therefore, we decided that the Plan has to pre-approveComputed Tomography (CT) of the Abdomen and Pelvis (74177).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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Q Logic Controller/Joystick Module (K0108) for the enrollee.You asked the Plan to pre-approvethe controller/joystick module. The Plan denied your request. The Plan says that Medicare rules state that this is already included in the expandable controller E2377 and harness E2313, and cannot be requested separately.The Plan must follow Medicare rules. Medicare rules state that code K0108 must not be used for any component or feature of an expandable controller at the time of initial issue. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the controller/joystick module have not been met.Therefore, we decided that the Plan does not have to pre-approvea Q Logic Controller/Joystick Module (K0108) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient specialist visit provided on October 17, 2019.
You asked the Plan to waive the copayment for the outpatient specialist visit. You say that you were in the hospital and you do not believe you should have a separate copayment from a doctor you do not remember seeing. 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 $35 copayment for each specialist visit, including outpatient clinic visits. For this date of service, you have been asked to pay the allowed amount of the claim because this amount is less than the $35 copayment for the outpatient specialist visit.
You have been asked to pay a $25.53 copayment for the outpatient specialist visit. The outpatient specialist visit falls within the "Outpatient hospital services" benefit category. The medical record shows you were seen by this provider while under observation.
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 specialist visit provided on October 17, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a duplex scan.
You asked the Plan to pre-approve a duplex scan. The Plan denied your request. The Plan says this is 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 a duplex scan. Our reviewer says that the requested duplex scan is not considered medically reasonable and necessary in this case. Our physician reviewer found that the member is a 67-year-old male with a history of obesity, hyperlipidemia, OSA, esophagitis and tobacco abuse. Per the reviewed documentation, he is not experiencing any signs of ischemia nor are there any physical exam findings to suggest limb ischemia. On the most recent clinical provided, the member had no complaints to suggest peripheral arterial insufficiency. The physical exam of the extremities was also normal. Furthermore, a recent ABI was not indicative of altered blood flow to the extremities. 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 duplex scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.You asked the Plan to pay for the ambulance services. You say that the Plan should review the medical records for the ambulance services and consider the services for payment.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on June 18, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay for the ambulance services
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Prolia injection (J0897).You asked the Plan to pre-approve a Prolia injection. You say that you requested coverage with Prolia because it is the only medication specifically approved for use in the setting of an aromatase inhibitor.The Plan denied your request. The Plan says the criteria has not been met as the enrollee has nottried an oral bisphosphonate such as Boniva or an IV bisphosphonate such as Reclast.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 Proliainjection. Our reviewer says that this enrollee does not meet the criteria for Prolia. Our physician reviewer found since the enrollee has not been treated with bisphosphonates, the Prolia would not meet the provided coverage criteria for this enrollee atthis time.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia injection have not been met.Therefore, we decided that the Plan does not have to pre-approve a Prolia injection (J0897).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 24, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that these services could have been provided by a primary care physician.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 provided on October 24, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvethe Aromasin 25mg tablet medication.You asked the Plan to pre-approvethis medication. You say that you are requesting a reconsideration of the Plan's denialfor thisbrand name medication as the enrollee has tried other formulations and has experienced significant side effects.The Plan denied your request. The Plan says this medication is not a covered benefit under the enrollee'scontractual policy.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approvethe Aromasin 25mg tablet medication.Benefits for this medicationmay be available under Medicare Part D.Contactthe 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 pre-approve an in-network exception for an out-of-network office visit.You asked the Plan to pre-approve an in-network exception forthe office visit. You say that you would like to continue to see this provider because the treatments you have received there are working.The Plan denied your request. The Plan says there are in-network providers in your region and no network inadequacies.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 your share of the costs for covered out-of-network services may be higher. We looked at your request, the file and the rules. Based on this information we have decided that criteria for the in-network exception have not been met. 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 pre-approve an in-network exception for an out-of-network office visit.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.You asked the Plan to pre-approve IRF care. You say that this is medically necessary.The Plan denied your request. The Plan says the guidelines have not been met for this admission.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at a lower level of care (ex. SNF/SAR).We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve the bone density scan provided on November 22, 2019.
You asked the Plan to pre-approve the bone density scan. The Plan denied your request. The Plan says that this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 bone density scan. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee is noted to have osteoporosis. The records indicate that in November 2018, the enrollee resumed taking Fosamax, a medication to treat osteoporosis. It is therefore reasonable to assume that the November 2019 DEXA scan was performed to assess the effectiveness of the resumed treatment. As such, the DEXA scan on November 22, 2019, was medically necessary and reasonable. 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 bone density scan have been met. Therefore, we decided that the Plan has to pre-approve the bone density scan provided on November 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay fora Cystography (74430) provided September 10, 2019 by University.You asked the Plan to pay for the Cystography. You say that services were medically necessary and properly billed.The Plan denied your request. The Plan says the records do not support the code billed.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 74430 is Cystography, minimum of three views, radiological supervision and interpretation.We find that CPT code 74430 is not supported in the medical record. Specifically, the enrollee underwent urodynamic testing.  The enrollee was able to void during the procedure and images were captured.  The procedure should be billed using a urodynamic testing code, not the code for cystography. The documentation does not support the billing of CPT 74430. Based on this information, we decided that Medicare rules forcoverage of the Cystography have not been met.Therefore, we decided that the Plan does not have to pay for a Cystography (74430) provided September 10, 2019 by University.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepermanent implantation of a spinal cord stimulator (SCS). You asked the Plan to pre-approvethe SCS implantation. You say that there has been an approval for the temporary trial and you wish to be able to proceed to permanent implantation if the trial is successful. You note that the enrollee is required to discontinue the use of his anti-coagulants for the procedure which puts him at greater risk for cardiac events.The Plan denied your request. The Plan says since there is no documented successful trial, the Plan is not able to approve permanent implantation.The Plan must follow Medicare rules. Medicare rules say that permanent implantation of an SCS device is covered only after a trial of the device is successful in reducing the enrollee's pain.In this case, there has not yet been a successful trial, so the Plan is not obligated to issue approval for the permanent placement.Therefore, we decided that the Plan does not have to pre-approve permanent implantation of a spinal cord stimulator (SCS).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the inpatient stay provided on November 11, 2019.
You asked the Plan to waive the cost share for the inpatient stay. You say that the coinsurance would put you over your maximum out-of-pocket. The Plan denied your request. The Plan says the cost share applied correctly.
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 your in-network deductible is $300. This is the amount you have to pay out-of-pocket before we will pay our share for your covered in-network medical services. The inpatient stay is not excluded from the deductible. Your contract with the Plan says that after your yearly deductible is met, you pay 10% per in-network stay. Your contract with the Plan says that the most you will have to pay out-of-pocket for in-network covered plan services in 2019 is $2,100.
The item or service you asked the Plan to waive the cost share for falls within the "Inpatient hospital care" benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that your $300 deductible applies to inpatient hospital care. This cost sharing is a contractual obligation that had not been met at the time the inpatient stay was received on November 11, 2019. Therefore, the remaining amount of $58.66 has been applied to the deductible.
Since your deductible was met, you have also been asked to pay $79.51, which is less than the standard coinsurance because you met your maximum out-of-pocket. 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 cost share for the inpatient stay provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network
provider on December 31, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at
issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that
the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider
on December 31, 2019.