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

We decided that the Plan does not have to waive the copayment foran office visit provided on April 3, 2019.You asked the Plan to waive the copayment foran office visit. 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 $10 copayment for physician/practitioner services, including doctor's office visits. You have been asked to pay a $10 copayment for an office visit. An office visit falls 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 foran office visit provided by on April 3, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a small travel CPAP device.You asked the Plan to pre-approvea small travel CPAP device. You say that you travel a lot and you cannot take your current CPAP with you.The Plan denied your request. The Plan says you have a CPAP and there is no record of compliance.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary.The file shows that you have a CPAP. The CPAP serves the same purpose as a smaller travelCPAP device.There is no compliance record or record of your CPAP not working. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home.Therefore, we decided that the Plan does not have to pre-approvea small travel CPAP device
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora yellow fever vaccine (90717) provided on September 4, 2019.You asked the Plan to pay fora yellow fever vaccine. You say that this was medically necessary.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 yellow fever vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to a yellow fever vaccine.Therefore, we decided that the Plan does not have to pay fora yellow fever vaccine (90717) provided on September 4, 2019.Benefits for a yellow fever vaccinemay 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 waive the copayment for the office visit provided on August 1, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you were informed there was no copayment. 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 $55 copayment for each Medicare-covered out-of-network podiatry visit. You have been asked to pay a $55 copayment for the office visit. The officevisit falls within the "Podiatry services" benefit category. The records show that the provider is an out-of-network podiatrist. 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 office visit provided on August 1, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay forthe inpatient psychiatric hospital services provided February24, 2019 to February 28, 2019.You asked the Plan to pay forthese services. You say that you are requesting reconsideration of the plan's denial for payment of the inpatient psychiatric admission.The Plan denied your request. The Plan says thatthe patient did not meet the medical necessity criteria for the inpatient level of care. All inpatient services require prior authorization.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient psychiatric hospital services. Our reviewer says that the inpatient psychiatric hospital services provided were medically necessary. Our physician reviewer found that based on the medical records provided, the patient was off his medications, depressed with a suicidal plan (with a history oftwo prior suicide attempts) and experiencing threatening auditory hallucinations. His medications were adjusted and his condition was reported to be improved at the time of discharge. The Health Plan did not show that their denial of continued inpatient psychiatric services was appropriate. The enrollee did require active inpatient mental health treatment.Additionally, the services were provided under an individualized treatment or diagnosticplan, supervised and evaluated by a physician. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met.Therefore, we decided that the Plan has to pay forthe inpatient psychiatric hospital services provided February 24, 2019 to February 28, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to you on August 19, 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 procedure code 99397 is not covered.The Plan must follow Medicare rules. The rules say that a status indicator of N represents a non-covered service.The provider submitted a claim for procedure code 99397 (established patient periodic preventive medicine examination, age 65 years and older). This code has a status indicator of N and is not covered by Medicare.Therefore, we decided that the Plan does not have to pay forthe services rendered to you on August 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug injection provided on October 8, 2019.You asked the Plan to waive the coinsurance fora Medicare Part B drug injection. You say that you were not informed that you would owe a copayment for the injection.The Plan denied your request. The Plan says the claims were processed correctly and you are being chargedthe 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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug injection on October 8, 2019. The allowed amount is $236.88 and 20% of that is $47.38. You have been asked to pay the total coinsurance amount of$47.38 for a Medicare Part B drug injection. A Medicare Part B drug injection falls 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 fora Medicare Part B drug injection provided on October 8, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not haveto pay forthe pathology services rendered on September 3, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plansays the services are not payable.The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC.The provider submitted a claim for procedure code 88305 (surgical pathology) once with the -26 modifier and once without a modifier. The file does not support that the PC and TC can be separately paid in this instance. The Plan has paid the claim for the global component.Therefore, we decided that the Plan does not have to pay forthe pathology services rendered on September 3, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prednisone tablets (J7512).You asked the Plan to pre-approvePrednisone tablets. You say that this is medically necessary.The Plan denied your request. The Plan says coverage of this medication is the responsibility of a prescription drug plan.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-approvePrednisone tablets (J7512).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pay forthe yellow fever vaccine received on September 4, 2019.You asked the Planto pay forthe vaccine. You say that this was provided prior to a trip to South America.The Plandenied your request. The Plansaysthis is not a covered benefit.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the vaccine.Therefore, we decided that the Plandoes not haveto pay forthe yellow fever vaccine received on September 4, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cell examination of a specimen (88112) provided on August 27, 2019 by out of network provider.You asked the Plan to pay forcell examination of a specimen. You say that you are appealing the claim payment denial for services rendered to your member on date of service August 27, 2019.The Plan denied your request.  The Plan says they did not authorize any services. The Plan says there are multiple in-network providers within 30 miles of the member's residence that could have rendered the services. The Plan says further that the services were not considered urgent/emergent in nature.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 forcell examination of a specimen (88112) provided on August 27, 2019 by out of network provider.
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 requested 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 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 fileand 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 require skillednursing 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 did not require skilled therapy services with the specializedskill, 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-approvean injection of substance into spinal canal of lower back or sacrum using imaging guidance (62323) to be provided by out of network provider.You asked the Plan to pre-approvean injection of substance into spinal canal of lower back or sacrum using imaging guidance. You say that you need the injections because you may lose the use of your leg and the doctor needs you to have the injections to see if surgery will be needed. You say that you do not wish to go to the provider and you want to be approved to have the epidural injections with the physician.The Plan denied your request. The Plan says you must use in-network providers for your medical care and services. The Plan says the only exceptions are emergencies, urgently needed services when the network is not available, out-of-area dialysis services and cases in which our plan authorizes use of out-of-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-approvean injection of substance into spinal canal of lower back or sacrum using imaging guidance (62323) to be provided by out of network provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says IRF admission is not medically necessary.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 that the complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee required the intensity of an IRF stay with close physician or nursing supervision. The enrollee may benefit and participate inadditional therapy of physical therapy and occupational therapy, but the enrollee's functional level does not require this on an intensive rehabilitation facility therapy program level in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids and molds.You asked the Plan to pre-approvethese services. You say that you have severe hearing loss.The Plan denied your request. The Plan says the services are not covered.The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related services. Though these services may be appropriate in this case, neither Medicare nor the Plan covers or pays for these types of items and services. The Plan's supplemental hearing aid benefit is covered by the Medicaid portion of your plan, not Medicare.Therefore, we decided that the Plan does not have to pre-approvehearing aids and molds.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on January 8, 2019 by out of network provider.You asked the Plan to pay forspecialist services. You say that you would like this claim approved for payment.The Plan denied your request. The Plansays no prior authorization was obtained for the services that were provided. The Plan says that the referring provider is also not-in-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 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 January 8, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approve BRCA 1 and 2 testing.You asked the Planto pre-approvethe testing. You say that this was requested by the doctor, after your mother and maternal aunt both died of ovarian cancer.The Plandenied your request. The Plansaysthere is no history of any cancer, other than prior skin cancer.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, the testing, is being requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plandoes not haveto pre-approveBRCA 1 and 2 testing
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for nurse practitioner services provided on August 13, 2019.You asked the Plan to pay for the nurse practitioner services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan 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 nurse practitioner services provided on August 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran office visit (99214) provided on August 22, 2019 by out of network provider.You asked the Plan to pay foran office visit. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service August 22, 2019.The Plan denied your request. The Plan says they did not authorize any services for the provider who is a non-participating provider. The Plan says that services are not considered urgent/emergent in nature. The Plan says that there are multiple in-network providers within 30 milesof the members residence that could have rendered the services. The Plan also says that authorization was not obtained as required under the Plan's 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 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 foran office visit (99214) provided on August 22, 2019 by out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for a diagnostic colonoscopy (45378) provided on May 24, 2019.You asked the Plan to pay fora diagnostic colonoscopy. You say that the surgical assistant could not refuse service.The Plan denied your request. The Plan says Medicare considers a surgical assistantnot reasonable and necessary for this service.The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1, assistant surgeon services are not covered. In this case, you billed assistant surgery services for CPT code 45378. The Medicare Fee Schedule Database contains a surgical indicator of 1 for this procedure. This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be paid. Based upon this information, we find that Medicare coverage criteria for a diagnostic colonoscopy have not been met.Therefore, we decided that the Plan does not have to pay fora diagnostic colonoscopy (45378) provided on May 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Cyclobenzaprine tablets.You asked the Plan to pre-approveCyclobenzaprine tablets. You say that this is medically necessary.The Plan denied your request. The Plan says coverage of this medication is the responsibility of your Part D prescription drug plan.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-approveCyclobenzaprine tablets.Benefits for Cyclobenzaprine tabletsmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.