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

We decided that the Plandoes not haveto pre-approve Neupro 8mg/24hr patches.You asked the Planto pre-approvethe Neupro patches. You say that this is medically necessary.The Plandenied your request. The Plansaysthis self-applied patch cannot be covered by 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 Plandoes not haveto pre-approveNeupro 8mg/24hr patches.Benefits for the Neupro patchesmay 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 nothave to pre-approvea trabeculoplasty by laser surgery (65855) to be provided by out of network provider.You asked the Plan to pre-approvea trabeculoplasty by laser surgery.. You say that you have been seeing the physician for the past 2 years, and he has been treating your glaucoma, and keeping it under control. You say that since he's been treating you for 2 years, you trust him to perform the surgery since the other physician told youshe didn'tknow howto treat her any longer.The Plan denied your request. The Plan says there is insufficient documentation to support a medical need for you to go outside of the plan's network for a trabeculoplasty. The Plan says they did not receive information to show that you were not able to get a trabeculoplasty from a network provider. The Plan says that enrollees must receive their care from a network provider except for emergency or urgently needed care, kidney dialysis services or if specialized medical care is not available from our in-network providers.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 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. 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-approvea trabeculoplasty by laser surgery (65855) to be provided by out of network provide
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on August 26, 2019 by out of network provider.You asked the Plan to pay foroutpatient lab work. 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 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 forthe medical services provided on August 26, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forchiropractic services provided from September 6, 2019 to October 11, 2019.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysan authorization for these services was not on file.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 Plandoes not haveto pay forchiropractic services provided from September 6, 2019 to October 11, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvePimecrolimus 1% cream for the enrollee.You asked the Planto pre-approvethe cream. You say that this is medically necessary.The Plandenied your request. The Plansaysthe enrollee has a medical only policy.The Plan must follow Medicare rules. The rules say that Medicare PartB 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 Plandoes not haveto pre-approvePimecrolimus 1% cream for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 31, 2019 to October 19, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not includethe carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from July 31, 2019 to October 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's anesthesia services provided on June 27, 2019.You asked the Plan to pay for the physician's anesthesia services. The Plan denied your request. The Plan says the services required 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 did not pre-approve the servicesat 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 anesthesia services provided on June 27, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe subsequent nursing facility care provided to the enrollee on December 14, 2018.You asked the Plan to pay forthese services. You say that you are not aware the of the enrollee's insurance when you the enrollee.The Plan denied your request. The Plan says that the enrollee does not have out of network benefits.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 andpre-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 subsequent nursing facility care provided to the enrollee on December 14, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory work provided on September 18, 2019.You asked the Plan to waive the copayment forthe laboratory work. You say that this copayment should have been covered under the first copayment for the lab work your received.  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 $10 copayment for diagnostic lab services and diagnostic procedures and tests (per day, per facility). You have been asked to pay a $10 copayment for the laboratory work. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. There is no provisionin the contract which indicates a copayment would be waived if performed as a follow-up.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 forthe laboratory work provided on September 18, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stelara.You asked the Plan to pre-approvethese services. You say that you disagree with the denial.The Plan denied your request. The Plan says self-administered drugs are not covered.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 Stelara.Benefits for these servicesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvegabapentin 400mg capsules.You asked the Planto pre-approvethe gabapentin capsules. You say that this is a medically necessary drug.The Plandenied your request. The Plansaysthis oral drug is not covered by 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 Plandoes not haveto pre-approvegabapentin 400mg capsules.Benefits for the gabapentin capsulesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair to be provided.You asked the Plan to pre-approve the power wheelchair. You say that the in-network providersare too far a distance and they do not provide power wheelchairs. The Plan denied your request. The Plan says the enrollee 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 pre-approve 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 and accessible who can provide the power wheelchair requestedin this appeal. We found no exception that would require the Plan to pre-approve the requested power wheelchair to be provided. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair to be provided.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe topical application of fluoride varnish, prophylaxis, first intraoral periapical x-ray, and periodic oral evaluation provided on September 24, 2019.You asked the Plan to pay forthe topical application of fluoride varnish, prophylaxis, first intraoral periapical x-ray, and periodic oral evaluation. You say that your Plan's customer service representative confirmed that you are covered for one bitewings x-ray and one periapical x-ray. You also say that your dentist uses the bitewing x-ray and two periapical x-rays to examine your teeth as a routine.The Plan denied your request. The Plan says topical application of fluoride varnish is not a covered benefit. The Plan also says that the benefits for the prophylaxis, first intraoral periapical x-ray, and periodic oral evaluation had been satisfied and the frequency limitations had been exceeded.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, topical application of fluoride varnish is not among those covered under this benefit. The contract also clearly states that prophylaxes, intraoral x-rays, and exams are each limited to one procedure per calendar year. The record shows that you received a prophylaxis and periodic oral evaluation on January 21, 2019 and your prophylaxis and exams benefits was 
then exhausted. The record also shows that you received an additional intraoral periapical x-ray on September 24, 2019, and your intraoral x-rays benefit was then exhausted. Therefore, we decided that the Plan does not have to pay forthe topical application of fluoride varnish, prophylaxis, first intraoral periapical x-ray, and periodic oral evaluation provided on September 24, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided from July 18, 2019 to October 6, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided  from July 18, 2019 to October 6, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost for the arthrocentesis provided on August 27, 2019.You asked the Plan to reduce the cost forthe arthrocentesis. You say that the provider shouldn't bill more money for the same services. You say that you do not agree with the higher obligation.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 a $290copayment per visit for Medicare-covered outpatient surgery in an ambulatory surgical center or hospital outpatient facility.You have been asked to pay $79.41, which is less than the standard $290 copayment for the arthrocentesis. The arthrocentesis falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to reduce the cost forthe arthrocentesis provided on August 27, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible and copayment fora colonoscopy provided on September 3, 2019.You asked the Plan to waive the deductible and copayment fora colonoscopy. You say that you disagree with the charges because this was a colonoscopy screening.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. Your contract with the Plan says that there is a $750 deductible. Your contract with the Plan also clearly says that after the $750 deductible has been met, enrollee's must pay a $125 copayment for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The medical records show that you had polyps removed during a colonoscopy on September 3, 2019. Therefore, the colonoscopy is considered diagnostic and you are responsible to pay your share of the cost-sharing charges. The record shows that you had paid $0 toward the $750 deductible prior to receiving the services. Therefore, you are responsible to pay the $750 deductible. Now that the deductible has been met, you are also responsible to pay the $125 copayment. The total amount you owe is: $875.00.The item or service you asked the Plan to waive the deductible and copayment for falls within the benefit category outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at the time a colonoscopy was received on September 3, 2019.Therefore, we decided that the Plan does not have to waive the deductible and copayment fora colonoscopy provided on September 3, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.The Plan must follow Medicare rules. 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 daily skilled services are not necessary. Our physician reviewer found this enrollee does not requireskilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment. This enrollee's functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist required to safely and effectively provide medically necessary and reasonable treatment in a SNF. The enrollee does not require these skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis". As a practical matter this enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve epidural injections in the back.You asked the Plan to pre-approve epidurals. You say that you are appealing with records.The Plan denied your request. The Plan says the denial of authorization for these services is correct, because the enrollee does not meet the Medicare criteria for the requested epidurals.The Plan follows Medicare rules. Medicare rules say that epidural injections are only covered for certain conditions whichsupport medical necessity.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 epidurals. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested epidurals. Our physician reviewer found no imaging report was submitted for review. There is no physical examination evidence of radiculopathy or sympathetic dysfunction. Physical therapy was ordered butthere are no details as to what therapy sessions have occurred and whether improvement was obtained. Therefore, at this point the requested epidurals are not medically reasonable and necessary.We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of epidurals have not been met.Therefore, we decided that the Plan does not have to pre-approveepidural injections in the back
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the prolonged service in the inpatient or observation setting coded 99356 provided on September 3, 2019.You asked the Plan to pay forthe prolonged service in the inpatient or observation setting. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 99356 is prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient Evaluation and Management service).We find that CPT code 99356 is not supported in the medical record. Specifically, the documentation does not support the time limit of prolonged service. Based on this information, we decided that Medicare rules for coverage of the prolonged servicein the inpatient or observation setting have not been met.Therefore, we decided that the Plan does not have to pay forthe prolonged service in the inpatient or observation setting coded 99356 provided on September 3, 2019.