Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for the services provided to the enrollee on August 28, 2019.You asked the Plan to pay for the services. You say that the enrollee was referred by an in-network provider.The Plan denied your request. The Plan says that the services were not authorized.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.The enrollee was referred for the services by a contracted provider. The file does not show that the plan provided notice that the services would not be covered. Under Medicare rules, this means the services is considered approved by the plan.Therefore, we decided that the Plan has to pay forthe services provided to the enrollee on August 28, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveelectrolysis.You asked the Plan to pre-approveelectrolysis. The Plan denied your request. The Plan says this is a cosmetic procedure.The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.  We looked at the file and Medicare rules. The requested electrolysis procedure is not required for the prompt repair of accidental injury or to improve the functioning of a malformed body member. Based on this information, we decided that Medicare rules for coverage of electrolysis have not been met.Therefore, we decided that the Plan does not have to pre-approveelectrolysis.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if theyare medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the provided medical records the enrollee is receiving necessary services and is at an appropriate level of care in the acute care hospital. Continued care at this level is appropriate until the enrollee is stable to transfer to a lower level of care such as an inpatient rehabilitation facility, a skilled nursing facility, sub-acute rehabilitation facility or home with home health services.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-approvelong term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay foroncology (urothelial) gene expression profile testing (Cxbladder test) provided on September 11, 2019.You asked the Plan to pay forCxbladder test. You say that this testing was medically necessary.The Plandenied your request. The Plan says the denial of payment for this service is correct, because this test is not covered by Medicare.The Plan must follow Medicare rules. Medicare rules say that Cxbladder testing was not covered by Medicare for date of service September 11, 2019. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Cxbladder test have not been met.Therefore, we decided that the Plan does not have to pay foroncology (urothelial) gene expression profile testing (Cxbladder test) provided on September 11, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe physician services provided on September 23, 2019 by an out of network (OON) provider.You asked the Plan to pay forthe physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.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 forthe physician services provided on September 23, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided from July 18, 2019 to September 5, 2019.
You asked the Plan to waive the coinsurance for the Part B injections. You say that you called and verified that the procedures were covered. You say you should only be responsible for the $20 office visit copayment. 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 15% of the total cost for Medicare Part B chemotherapy drugs, associated administration services and all other Medicare Part B drugs.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Monovisc injections provided on October 7, 2019.
You asked the Plan to waive the coinsurance for the Monovisc injections. You say that you were advised this would be covered in full. You say that the charge should be negated. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each Medicare-covered Part B drug. You have been asked to pay $302.86, which is 20% of the allowed amount for the Monovisc injections. The allowed amount is $1,514.32 (20% x $1,514.32 = $302.86). The Monovisc injections fall within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Monovisc injections provided on October 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvelong term acute care hospital (LTACH) services.You asked the Plan to pre-approvethe LTACH services. You say that the records provided support the need for LTACH care.The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met.The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee continues to require acute hospital level of care services and is receiving appropriate care at the present acute care facility. The review has determined that the enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health planWe 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-approvelong term acute care hospital(LTACH) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from June 24, 2019 to July 9, 2019.You asked the Plan to pay fo rthe skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act.The Plan denied your request. The Plan says the enrollee did not require any additional skilled services that could not have been provided in an alternate settingother than a SNF.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 pay for the skilled nursing services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met.Therefore, we decided that the Plan does not have to pay forthe skilled nursing services provided from June 24, 2019 to July 9, 2019
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve breast reduction surgery.You asked the Planto pre-approvethe surgery. You say that this is medically necessary.The Plandenied your request. The Plansaysthatit is not medically reasonable or safe at this time for the enrollee to undergo the procedure, due to elevated rates of complications in patients with higher BMIs.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 surgery. Our reviewer says that the requested surgery is considered medically reasonable and necessary in this case. Our physician reviewer found the health plan has placed an arbitrary cut-off for denying this medically necessary procedure. As long as you understand your increased risk of complication and have provided informed consent, the procedure should be considered medically necessary as defined by Medicare.  Having to have a BMI at 30 is an arbitrary cut-off that should not preclude medical necessity. There is no evidence that this is performed for convenience. Breast reduction for you is not experimental or investigational. The procedure should be considered appropriate for you despite the increased risk of complication, as long as a well informed consent process has been completed. Offering this procedure for you is consistent with standard of care. Breast reduction would not exceed your medical need and there is no other viable alternative to help with your severe functional impairment.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the surgery have been met.Therefore, we decided that the Planhas to pre-approvebreast reduction surgery.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 16, 2019.You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan 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 provided on September 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care provided on August 21, 2019 by an out of network (OON) provider.You asked the Plan to pay for observation care. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained 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 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 observation care provided on August 21, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve chiropractic services to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve out-of-network chiropractic services. You say that this is the only doctor who has successfully treated your vertigo. The Plan denied your request. The Plan says the requested services are available in the Plan's network.
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 chiropractic 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 pay formassage therapy (97124) provided from August 17, 2018 to July 1, 2019.You asked the Plan to pay formassage therapy. You say that these services should be paid.The Plan denied your request. The Plan says massage therapy is not covered by Medicare or the Plan.The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist.Therefore, we decided that the Plan does not have to pay formassage therapy (97124) provided from August 17, 2018 to July 1, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora hepatitis A and B vaccine (90636) and administration (90471).You asked the Plan to pay fora hepatitis A and B vaccine and administration. You say that this should be covered because you are traveling to South America.The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your Part D prescription drug plan.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a hepatitis A and B vaccine and administration.The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a hepatitis A and B vaccine (90636) and administration (90471).Therefore, we decided that the Plan does not have to pay fora hepatitis A and B vaccine (90636) and administration (90471).Benefits for a hepatitis A and B vaccine and administrationmay be available under Medicare Part D.Contactthe Planthat administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit rendered on July 17, 2019.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that procedure code 99213 is not payable.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward 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 states that code 99213 (office visit) has a status indicator of B and no separate Medicare payment; however, this code has a status indicator of A and is active under Medicare OPPS payment. The Plan has not provided any rules or documentation to support that code 99213 is not separately payable. Therefore, we decided that the Plan has to pay for the office visit rendered on July 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share foroutpatient services provided from June 19, 2019 through June 27, 2019. You asked the Plan to waive the cost share foroutpatient services. You say that you disagree with the outpatient level of care. You say that knee surgery is covered under inpatient level of care. 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 (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $5 copayment for each Medicare-covered laboratory test,20% of the cost for Medicare-covered diagnostic procedures and tests,a $15 copaymentfor each Medicare-covered x-ray, 20% of the cost for Medicare-covered medical supplies, 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs, a $250 copayment for each Medicare-covered outpatient hospital facility visitand a $40 copayment for each Medicare-covered physical therapy visit.You have been asked to pay a total of $1,382.69for outpatientservices. The laboratory services, blood oxygen level tests, x-rays and medical suppliesfallwithin the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category.The pharmacy services and drugs fall within the "Medicare Part B prescription drugs" benefit category. The knee replacement falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The physical therapy falls within the "Outpatient rehabilitation services" benefit category. The records show that the services were provided in an outpatient level of care. 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 foroutpatient services provided from June 19, 2019 through June 27, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on April 25, 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 there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe drug testing rendered on April 25, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the tumor treatment field therapy (TTFT) provided from September 11, 2019 to November 11, 2019.
You asked the Plan to pay for the TTFT services. You say that this should be covered by the plan due to the limited treatment options remaining to the patient and due to the efficacy of this treatment. The Plan denied your request. The Plan says this is not covered for treatment of recurrent GBM. This enrollee had already received this treatment when newly diagnosed and re-treatment for recurrence is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that TTFT for treatment of recurrent GBM will be denied as not medically reasonable and necessary. We looked at the file and Medicare rules. The documentation clearly demonstrates recurrence of GBM. Based on this information, we decided that Medicare rules for coverage of the TTFT services have not been met. Therefore, we decided that the Plan does not have to pay for the tumor treatment field therapy (TTFT) provided from September 11, 2019 to November 11, 2019.