Persius/hicric huggingface dataset:
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjust complete denture -maxillary and adjust complete denture -mandibular provided on October 29, 2019.You asked the Plan to pay for the complete denture adjustments. You say that this should not be out-of-network until the end of the year. You also say that you are having issues with your dentures and this is the provider who gave them to you and is repairing them free of charge.The Plan denied your request. The Plan says services done by an out-of-network provider are not covered. The Plan also says that the dentist that provided this treatment is not part of the Plan's network.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 out-of-network.Therefore, we decided that the Plan does not have to pay for the adjust complete denture -maxillary and adjust complete denture -mandibular provided on October 29, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 99223) provided to the enrollee on September 17, 2019.You asked the Plan to pay forthe services. You say that the claim was billed correctly.The Plan denied your request. The Plan says an inpatient service code is not appropriate.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 99223 is "Initial hospital inpatient care, typically 70 minutes per day".We find that CPT code 99223 is not supported in the medical record. Specifically, the enrollee was under outpatient status on the date of service in question. It is inappropriate to bill an inpatient E&M code while the enrollee is under outpatient status. Based on this information, we decided that Medicare rules for coverage of the services have not been met.Therefore, we decided that the Plan does not have to pay forthe services (CPT 99223) provided to the enrollee on September 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on July 22, 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 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 for the drug testing rendered on July
22, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to enrollee on April 18, 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 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 for the drug testing rendered to enrollee on April 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered on March 28, 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 the claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay forthe drug testing renderedl on March 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infrared therapy (97026) provided from September 20, 2019 to October 24, 2019.
You asked the Plan to pay for infrared therapy. You say that this should be covered. The Plan denied your request. The Plan says infrared therapy is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered. We looked at the file and Medicare rules. The services at issue are non-covered infrared therapy services. Based on this information, we decided that Medicare rules for coverage of infrared therapy have not been met. Therefore, we decided that the Plan does not have to pay for infrared therapy (97026) provided from September 20, 2019 to October 24, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the column chromatography rendered on March 18, 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 the services were not medically necessary.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the enrollee had a hiatal hernia, gastroesophageal reflux disease (GERD), and a failed Nissen procedure. He is on long term Domperidone, with increased pressure and bloating of central abdomen. The main principle involved in column chromatography is adsorption of the solutes of a solution through a stationary phase and separates the mixture into individual components. This is based on the affinity towards the mobile phase and stationary phase. The column chromatography is not the standard of care for the enrollee's condition. It was not reasonable and medically necessary for the enrollee to have thecolumn chromatography We looked at this physician's review, the file, and Medicare rules. 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 column chromatography rendered on March 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on July 8, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plansays 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 to the enrollee on July 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided to the enrollee on August 16, 2019.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says it cannot be determined whether the services are medically necessary.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met. 

We looked at the file and Medicare rules. The documentation submitted by the non-contract provider does not contain medical records for the date of service in question. Without records, it cannot be determined that Medicare covered criteria have been met. Therefore, we decided that the Plan does not have to pay for the services provided to the enrollee on August 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital outpatient clinic visit provided on August 29, 2019.
You asked the Plan to pay for the hospital outpatient clinic visit. 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 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 hospital outpatient clinic visit provided on August 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve automatic blood pressure cuff You asked the Plan to pre-approve automatic blood pressure cuff. You say that you were diagnosed with heart failure and feel that this should be covered because your provider recommended you to get it.The Plan denied your request. The Plan says this item is not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare covers home blood pressure monitors only for enrollees who are on home dialysis.Records show that you are not on home dialysis. Although a home blood pressure monitor may be appropriate in this case, neither Medicare nor the Plan provides coverage of this item for your condition.Therefore, we decided that the Plan does not have to pre-approve automatic blood pressure cuff
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. 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 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 records do not indicate that there are significant, or complex medical/nursing issues
that could not be addressed at a skilled nursing facility (SNF) level of care. Ongoing pain medication and other
medication management, wound/skin care, and daily therapy can be provided at a SNF. In this case, the
enrollee is mostly standby assist for functional transfers and activities of daily living (ADL's) and a less
intensive, longer duration of therapy will allow for measurable gains to be attained within a reasonable period.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on September 26, 2019.
You asked the Plan to pay for the laboratory 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 laboratory services. 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 laboratory services provided on September 26, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from August 1, 2019 to
August 15, 2019.
You asked the Plan to pay for the home health services. The Plan denied your request. The Plan says nonemergent,
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
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 home health services provided from August 1, 2019 to August
15, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99308) provided on September 18, 2019 to September 25, 2019
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not preauthorized or emergent. There were in-network providers available that could have provided 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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the nursing facility care (99308) provided on September 18, 2019 to September 25, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLTACH services for the enrollee. You asked the Plan to pre-approvethe LTACH services. The Plan denied your request. The Plan says the enrollee is receiving appropriate care at the current acute care facility.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 physician reviewer found that the enrollee was admitted to the acute hospital for worsening pneumonia and hypoxia. The enrollee is receiving appropriate care at the current acute care facility. 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 plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.You asked the Plan to pre-approve the Aranesp. You say that Aranesp is medically necessary and should be approved.The Plan denied your request. The Plan says the requested drug is subject to step therapy and there is no evidence that the enrollee has tried Retacrit.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 the Aranesp. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the records do not show that the enrollee tried and failed treatment with Retacrit. The documentation provided does not support that Retacrit would have likely been less effective or have had 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 the Aranesp have not been met.Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe CYP2C19 genetic testing 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 Plan says the testing is not covered.The Plan must follow Medicare rules. The rules say that genetic testing of the CYP2C19 gene is considered medically necessary for patients with ACS undergoing PCI who are initiating or reinitiating Clopidogrel (Plavix) therapy.We looked at the file and Medicare rules. The file does not show that the testing was performed for the enrollee with acute coronary syndrome undergoing percutaneous coronary intervention.Therefore, we decided that the Plan does not have to pay forthe CYP2C19 genetic testing on September 3, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Mavenclad.You asked the Plan to pre-approve Mavenclad. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Mavenclad is not covered under the enrollee's Medicare Part B benefit.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-approveMavenclad.Benefits for Mavencladmay 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: Favorable

We decided that the Plan has to pay forthe physician services provided on March 18, 2019 and September 19, 2019.You asked the Plan to pay for the physician services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says that the services were not authorized.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. Specifically, you say that you have been seeing this cancer doctor for years and it is imperative for your recovery that you continue to see this cancer doctor. The Plan confirmed that you have been seeing this cancer doctor since 2017. Per Medicare guidelines, Plan's must arrange for specialty care outside of the Plan provider network when network providers are unavailable or inadequate to meet an enrollee's medical needs. In this case, the Plan has not substantiated their reasoning for denial as the Plan did not address the continuity of care concern and did not provide documentation showing that there were Plan specialists available to you that you could have transitioned your care to if medically appropriate.Therefore, we decided that the Plan has to pay forthe physician services provided on March 18, 2019 and September 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve BAQSIMI two pow 3 mg/dose.You asked the Plan to pre-approveBAQSIMI two pow 3 mg/dose. You say that the medication is necessary.The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefitor a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.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-approveBAQSIMI two pow 3 mg/dose.Benefits for BAQSIMI two pow 3 mg/dosemay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for arthrocentesis provided on September 10, 2019.
You asked the Plan to waive the copayment for arthrocentesis. You say that you were only charged $47.76 for
the same procedure in the past. 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 $250
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and
ambulatory surgical centers.
You received arthrocentesis at an outpatient hospital facility on September 10, 2019. Arthrocentesis is an
outpatient surgical procedure. Therefore, you are responsible to pay the $250 copayment.
You have been asked to pay a $250 copayment for arthrocentesis. Arthrocentesis falls within the outpatient
surgery and other medical 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 waive the copayment for arthrocentesis provided on September 10, 2019.