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

We decided that the Plan does not have to waive the copayments for the laboratory work provided on January 31, 2020 and February 7, 2020.
You asked the Plan to waive the copayments for the laboratory work. You say that you were billed incorrectly. 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 $20 copayment per visit for laboratory tests, non-radiological tests, flat film x-rays, and ultrasounds. For each date of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $20 copayment for the laboratory work.
You have been asked to pay a $12.37 copayment for the laboratory work on each date of service. The laboratory work falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 copayments for the laboratory work provided on January 31, 2020 and February 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on September 4, 2019.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because the documentation submitted does not include a valid physician order, lab requisition, or medical
records to support the lab code billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided
that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing provided on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on February 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the nursing facility care. You say that you would like reconsideration because the member is unable to leave her place of care. The Plan denied your request. The Plan says there is not a prior authorization 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 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 medical services provided on February 18, 2019 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services.
You asked the Plan to pre-approve continued services. The Plan denied your request. The Plan says your ability
to cope with stress has improved.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the
patient requires active treatment.
Continued services beyond July 20, 2020, were requested. 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 continued services. Our physician reviewer found that it did not appear that the services are
reasonably expected or medically necessary to improve your condition, or for the purpose of diagnosis. You do
not meet the criteria for treatment in an acute inpatient mental health treatment beyond July 20, 2020, and
could be treated in a lesser restrictive setting. You were not showing any substantive suicidal or homicidal
ideation, auditory or visual hallucinations, delusions. You were not showing any behaviors or aggression being
cooperative and compliant while not showing any acute threats to safety or withdrawal symptoms.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued services have not been met. Therefore, we decided that the Plan does
not have to pre-approve continued inpatient psychiatric services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) rendered by the
out of network (OON) provider on December 20, 2019.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without 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 provider in this case is not a network provider with the Plan. The Plan has network providers available
who can provide the service 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 this service. Therefore, we decided that the Plan does not
have to pay for the subsequent nursing facility care (99308) rendered by the out of network (OON) provider on
December 20, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana.
You asked the Plan to pre-approve Brovana. You say that brovana is medically necessary. The Plan denied
your request. The Plan says a trial of formoterol is required before alternatives can be considered.
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 Brovana. Our reviewer says that
Brovana is not medically necessary. Our physician reviewer found the health plan requires that formoterol be
used first. There is no evidence that the enrollee is allergic to or intolerant of formoterol. There is no evidence
that the enrollee has tried and not responded formoterol. There is no documentation as to why formoterol
would not be expected to be safe and effective 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 Brovana have not been met. Therefore, we decided that the Plan does not have
to pre-approve Brovana.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the custom fabricated abutment (D6057) provided on
January 15, 2020.
You asked the Plan to pay for the custom fabricated abutment. You say that per page 114 of the Plan's 2020
Evidence of Coverage, dental implant is covered. You also say that the insurance covered the surgery
procedure to put the abutment on, but denied coverage of the abutment. The Plan denied your request. The Plan
says this service is not covered by the Plan.
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
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the
custom fabricated abutment (D6057) provided on January 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing provided on June 20, 2019.
You asked the Plan to pay for drug test. You say that you have submitted a valid physician laboratory
requisition form. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because the documentation submitted does not include a valid physician order, lab requisition, or medical
records stating exactly which tests were to be performed.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific
lab services is required for covered lab services.
We looked at the file and Medicare rules. The documentation submitted does not include a valid physician
order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided
that Medicare rules for coverage of drug test have not been met. Therefore, we decided that the Plan does not
have to pay for drug testing provided on June 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for cataract removal provided on February 24,
2020.
You asked the Plan to waive the copayment for cataract removal. You say that services were provided at a
surgery center. 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 $325
copayment for outpatient surgery, including services provided at hospital outpatient facilities.
The record shows that you had cataract removal at an outpatient hospital facility on February 24, 2020.
Therefore, you are responsible to pay the $325 copayment.
You have been asked to pay a $325 copayment for cataract removal. Cataract removal 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 waive the copayment for cataract removal provided on
February 24, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the surgery. You say that you would like reconsideration because the surgery was medically necessary. The Plan denied your request. The Plan says the provider failed to request prior authorization before rendering services and there is no evidence of plan directed care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan 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 medical services provided on November 18, 2019 by an out of network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient admissions provided from January 1, 2020 to January 3, 2020 and from January 13, 2020 to January 18, 2020.
You asked the Plan to pay for the inpatient admissions. You say that the hospice status was revoked. The Plan denied your request. The Plan says when an enrollee enrolls in a Medicare-certified hospice program, hospice services and Part A and Part B services related to the terminal prognosis are paid for by Original Medicare, not our plan.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on January 1, 2020 and again on January 13, 2020. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for inpatient admissions provided from January 1, 2020 to January 3, 2020 and from January 13, 2020 to January 18, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 22, 2019 to August 2,
2019 by an out of network (OON) provider.
You asked the Plan to pay for the office visits (99213 and 99214), aspiration (20611) and methylprednisolone
acetate injection (J1030). You say that you would like reconsideration because the specialized care has not
been considered. The Plan denied your request. The Plan says the member must get the plans approval before
getting care from providers not in their plan unless it's for urgent care, emergency care or renal dialysis outside
the service area.
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 medical services provided on April 22, 2019 to
August 2, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient hospital services rendered on
March 28, 2020.
You asked the Plan to waive the copayment for these services. You say that the services were a continuation
from the first visit. The Plan denied your request. The Plan says the copayment was 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). The enrollee's contract with the Plan clearly says that enrollees
must pay a $250 copayment for outpatient hospital observation services.
Review of the file shows that the enrollee received outpatient hospital services on March 28, 2020. The
enrollee has been asked to pay a $250 copayment for these services. These services fall within the outpatient
hospital observation 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. There are no continuation of services rules regarding copayments for outpatient
services. Therefore, we decided that the Plan does not have to waive the copayment for the outpatient hospital
services rendered on March 28, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a pneumatic compression device (E0673, E0650).
You asked the Plan to pay for a pneumatic compression device. You say that the claim should be paid. The
Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to
prevent deep vein thrombosis during and/or following surgery.
The provider must follow Medicare rules. The rules state that items that are used for a preventative service or
function are excluded from coverage under the Medicare DME benefit.
The submitted documentation reflects that the enrollee was prescribed an intermittent limb compression device
for the prevention of deep vein thrombosis (DVT) following knee surgery. As such, this was applied as a
preventative service, which is not covered. Based on this information, we decided that Medicare rules for
coverage of a pneumatic compression device have not been met. Therefore, we decided that the Plan does not
have to pay for a pneumatic compression device (E0673, E0650).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive all cost sharing for all future services from the physician for the enrollee.
You asked the Plan to waive all cost sharing for these services. You say that the enrollee should be not responsible because the physician provided inadequate care. The Plan denied your request. The Plan says cost sharing is a contractual obligation that cannot be waived.
The 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 $20 copayment per visit for primary care visits.
If the enrollee chooses to receive primary care visit services, they will be asked to pay a $20 copayment per visit for these services. These services fall within the primary care visits benefit category. This means that the enrollee will be asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation they agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive all cost sharing for all future services from the physician.
Your complaint about the physician is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a (dynasplint) dynamic adjustable toe extension flexion device (E1830).
You asked the Plan to pre-approve the special foot brace. You say that the splint is necessary to treat the enrollee's toe. The Plan denied your request. The Plan says this specific brace is not needed for your problem.
The Plan must follow Medicare rules. Medicare rules say that this device is medically necessary for use under certain conditions for the following joints: elbow, wrist, finger, or knee. The enrollee has a fixed contracture in their toe. This specific brace is not covered for this problem or for the toe.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of special foot brace have not been met. Therefore, we decided that the Plan does not have to pre-approve a (dynasplint) dynamic adjustable toe extension flexion device (E1830).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve companion care.
You asked the Plan to pre-approve the companion care. You say that you have congestive heart failure, circulation issues in your legs, many types of arthritis in your back and joints, lymphedema, and diabetes. You say you do not want to use this service every day but you need help getting to and from doctor's appointments. The Plan denied your request. The Plan says you do not meet 2 or 3 of the Medicare requirements, which are a high risk of hospitalization or other adverse health outcomes and require intensive care coordination.
The contract with the Plan says you must complete an in-home health assessment to determine eligibility for companion care. We looked at the file and the Plan's rules. The file shows based on your in-home health assessment, you do not qualify for companion care at this time because you did not meet one or more of the requirements. Therefore, we decided that the Plan does not have to pre-approve companion care.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for home oxygen equipment provided to the enrollee as of January 30, 2019.
You asked the Plan to pay for this equipment. You say that this equipment was medically necessary. The Plan denied your request. The Plan says Oxygen and Respiratory Equipment these services may be covered if your medical records show a diagnosis of severe lung disease or hypoxia-related symptoms or findings such as pulmonary hypertension or recurring congestive heart failure. The medical records provided by the doctor do not show that he meets criteria. Also, based on Provider Policy and Procedure Manual, Providers of service must submit corrected claims within one hundred eighty (180) days after the month of service to be eligible for full reimbursement. Therefore, the request for payment of Home Health Services on 01/30/2019 by Arrow Respiratory Care remains denied. Please follow up with the provider for alternative treatment options.
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient must have tried other alternative treatments without complete success. The patient must meet one of the following blood gas levels: 1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during sleep for a patient who have hypoxia symptoms during sleep;
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for patients who have hypoxia symptoms during exercise; 4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of dependent edema, pulmonary hypertension, or erythrocythemia. The medical records provided do not show the enrollee met the criteria needed for home oxygen. There were no specific pulmonary reports, a sleep study was ordered but does not show complete and the respiratory evaluation states normal function. Based on this information, we decided that Medicare rules for coverage of this equipment have not been met. Therefore, we decided that the Plan does not have to pay for home oxygen equipment provided to the enrollee as of January 30, 2019.