Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the IRF admissionismedically necessary.The Plan denied your request. The Plan says the patient does not meetcriteria for coverage of an IRF 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 reviewerto 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 necessarybased on Medicare guidelines. Our physician reviewer found the complexity of the patient'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 patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in physicaland occupational therapy,but the patient 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-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Onetouch ultra blue test strips.You asked the Plan to pre-approve Onetouch ultra blue test strips. You say that the requested items are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan follows Medicare rules. Medicare rules say that plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers as long as the enrollee retains access to all medically necessary items (including non-preferred brands).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 Onetouch ultra blue test strips. Our reviewer says that the items are not medically necessary. Our physician reviewer found the requested test strips are not the preferred brand as outlined by the plan. Documentation does not include a supporting rationale for non-preferred glucose testing strips and meter. Without the support of the documentation, medical necessity cannot be determined.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Onetouch ultra blue test strips have not been met.Therefore, we decided that the Plan does not have to pre-approveOnetouch ultra blue test strips.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora hip brace with abduction orthosis (L1686, L2624) provided to the enrollee on August 16, 2019.You asked the Plan to pay for the orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered.Therefore, we decided that the Plan does not have to pay fora hip brace with abduction orthosis (L1686, L2624) provided to the enrollee on August 16, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Actemra (tocilizumab).You asked the Plan to pre-approve Actemra. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee has not tried Remicade or Inflectra and Simponi Aria.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 Actemra. Our reviewer says that thecriteria for coverage of Actemra have not been met. Our physician reviewer found the Plan requires a trial of either Remicade or Inflectra and Simponi Aria before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drugs or that these drugs would likely be less effective or have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Actemra have not been met.Therefore, we decided that the Plan does not have to pre-approveActemra (tocilizumab).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic x-ray and prophylaxis provided on September 25, 2019.
You asked the Plan to pay for the panoramic x-ray and prophylaxis. You say that it was not clear from your insurance card that this was a Medicare Plan and the dentist informed you of this prior to the services being rendered. You also say that after the dental work was completed, you and your provider were informed that the services were not covered. The Plan denied your request. The Plan says this dentist is a non-contracted provider. The Plan also says that services performed outside of the provider network are not a benefit.
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, the requested items or services are not covered when they are received by a non-contracted provider. Therefore, we decided that the Plan does not have to pay for the panoramic x-ray and prophylaxis provided on September 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on October 2, 2019.
You asked the Plan to waive the cost-share for the ambulance services. You say that you called 911 because your husband was unresponsive and because he has a history of stroke. You say that the ambulance came and checked him over and decided he had no signs of stroke and they checked his sugar level and they helped him to the couch and then left. The Plan denied your request. The Plan says the claim was processed according to the Plan's ambulance services for non Medicare-covered ambulance stabilization when there is no transport.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. However, the Plan offers a benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Medicare rules say a Plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). The enrollee's contract with the Plan clearly says that enrollees must pay a $200 copayment for each non Medicare-covered ambulance stabilization when there is no transport. The ambulance company did not provide transport services on October 2, 2019. The ambulance benefit is a transportation benefit. The Plan offers an ambulance benefit for non Medicare-covered ambulance stabilization when there is no transport. The enrollee has been asked to pay $200 for the ambulance services. This falls within the ambulance services benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the cost-share for ambulance services provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services you received from an opt-out provider on January 22, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this provider has opted out of Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation a provider who has opted out of the Medicare program. Thefile shows that the provider entered into a private contract with you regarding payment.Therefore, we decided that the Plan does not have to pay forthe services you received from an opt-out provider on January 22, 2019
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 11, 2019.You asked the Plan to waive the copayment for laboratory services. You say that this was part of your annual physical. You say that you have never been charged before.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 $20 for Medicare-covered laboratory tests. You have been asked to pay a $20 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 forlaboratory services provided on September 11, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services (98942) provided on October 15,
2019 by an out of network (OON) provider.
You asked the Plan to pay for chiropractic services. You say that your provider told you to see a chiropractor.
The Plan denied your request. The Plan says these services were received out-of-network without
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 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 the chiropractic services (98942) provided on
October 15, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aciphex for the enrollee.You asked the Plan to pre-approveAciphex. The Plan denied your request. The Plan says that this is not covered under Part B.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pre-approveAciphex for the enrollee.Benefits for Aciphexmay 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 pay for an office visit provided on September 7, 2018 by an out of network (OON) provider.You asked the Plan to pay forthe out-of-network office visit. You say that the claim should be reprocessed for payment because the enrollee really needed to be seen and came to the provider their law office referred them to.The Plan denied your request. The Plan says there was no authorization for the out-of-network services in dispute.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 provided on September 7, 2018 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have topay fora comprehensive hearing test (92557) provided on July 15, 2019 by an out of network (OON) provider.You asked the Plan to pay fora comprehensive hearing test. You say that this claim should be reprocessed.The Plandenied your request. The Plan says this service was 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 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 fora comprehensive hearing test (92557) providedon July 15, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture services you received on August 19, 2019.
You asked the Plan to pay for the acupuncture services. The Plan denied your request. The Plan says this is not
a covered service.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare.
The services at issue in this appeal are acupuncture services. Therefore, we decided that the Plan does not have
to pay for the acupuncture services you received on August 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 30, 2019.
You asked the Plan to pay for the orthosis. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for a lumbar-sacral orthosis (L0650) provided to the enrollee on September 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a genicular nerve block (64450, 77003, 99152) of the knee.You asked the Plan to pre-approve the nerve block. You say that the procedure is medically necessary.The Plan denied your request. The Plan says the procedure is investigational for your condition and therefore is not covered.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 nerve block. Our reviewer says that coverage criteria has not been met. Our physician reviewer found the medical literature shows that a genicular nerve block in this application is considered investigational at this time. The record does not show that the enrollee is enrolled in an approved clinical trial.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 nerve block have not been met.Therefore, we decided that the Plan does not have to pre-approve a genicular nerve block (64450, 77003, 99152) of the knee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran office visit provided on July 3, 2019.You asked the Plan to waive the copayment foran office visit. You say that you went for your annual wellness exam. You say that you had bronchitis when you went but that was not the reason for the visit.The Plan denied your request. The Plan says additional services were provided that went beyond an annual wellness exam; therefore, the correct copayment has been applied.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 clearlysays that you must pay a $5 copayment for physician/practitioner services/primary care physician. You have been asked to pay a $5 copayment for an office visit. Since additional services were provided outside of an annual wellness exam the correct copayment has been applied. An office visit falls within the physician/practitioner services/primary care physician 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 on July 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on March 19, 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 procedure code G0483 is not supported.
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 G0483 is definitive drug testing, 22 or more classes. We find that CPT code G0483 is not supported in the medical record. Specifically, there is no documentation of testing of 22 or more drug classes. 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 for the drug testing rendered on March 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the posterior resin-based composite provided on September 9, 2019.You asked the Plan to pay for the posterior resin-based composite. You say that you are unable to pay this amount. You also say that you already paid them $150 at the time of the services.The Plan denied your request. The Plan says these services were performed by an out-of-network provider and you are responsible for any difference between the Maximum Allowable Fee and the amount the provider bills you for these services. The Plan also says that your benefits have been satisfied and the frequency limitation has 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, restorations are limited to two procedures per calendar year. The record shows that you received 3 resin-based composites on September 9, 2019, two of which the Plan paid at the out-of-network rate, and your benefit for restorations was then exhausted.Therefore, we decided that the Plan does not have to pay for the posterior resin-based composite provided on September 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous ablation of the veins.You asked the Plan to pre-approveendovenous ablation. You say that the appropriate treatment for the enrollee's condition is radiofrequency ablation therapy.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because Medicare criteria requires a BMI of less than 35 but the enrollee's BMI is not within this range.The Plan follows Medicare rules. Medicare rules say that treatment of varicose veins and venous stasis disease is only covered when the enrollee meets certain specific criteria, including documented weight reduction to a body-mass index (BMI) of less than 35.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 endovenous ablation. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested endovenous ablation therapy. Our physician reviewer found the enrollee does not have documented weight reduction to a body-mass index (BMI) of less than 35.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of endovenous ablation have not been met.Therefore, we decided that the Plandoes not have to pre-approveendovenous ablation of the veins.