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

We decided that the Plan does not have to pre-approve a computed tomography (CT) scan of the abdomen/pelvis 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We looked at the file and Medicare rules. There is no documentation in the file to support that the CT scan is reasonable and medically necessary at this time. The Plan made attempts to obtain records for the appeal but did not receive a response. 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 pre-approve a computed tomography (CT) scan of the abdomen/pelvis
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse you forthe infrared therapy rendered to you on October 26, 2018 to November 8, 2018.You asked the Plan to reimburse you forthese services. You say that you disagree with the reimbursement amount.The Plan denied your request. The Plan says the claim was reimbursed 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 20% coinsurance for out-of-network services in Puerto Rico. Review of the file shows that you received infrared therapy from an out-of-network provider in Puerto Rico from October 26, 2018 to November 8, 2018. You have been asked to pay a 20% coinsurance for these services. These services fall within the out-of-network services in Puerto Rico 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 reimburse you forthe infrared therapy rendered to you on October 26, 2018 to November 8, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa (J7323).
You asked the Plan to pre-approve the Euflexxa. You say that the Euflexxa is medically necessary for the treatment of the member's condition. The Plan denied your request. The Plan says the member does not meet criteria for a step therapy exception.
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 Euflexxa. Our reviewer says that the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Our physician reviewer found Euflexxa is not approved as step therapy exception criteria have not been met.
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 Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve psychotherapy services.
You asked the Plan to pre-approve psychotherapy services. The Plan denied your request. The Plan says this is not medically necessary.
The Plan follows Medicare rules. Medicare rules say that psychotherapy services are covered when they are medically necessary. 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 psychotherapy services. Our reviewer says that the requested psychotherapy services are not medically reasonable and necessary. Our physician reviewer found that the enrollee had a psychiatric evaluation performed on January 6, 2020. She has been taking Xanax and denied any suicidal/homicidal ideation, auditory or visual hallucinations. The requested sessions as noted above, would not meet the criteria for medical necessity as there are no documented active symptoms. Based on review the records provided, the request for outpatient psychotherapy is not reasonable or medically necessary utilizing LCD 34616, as this enrollee is not showing acuity of symptoms, goal-directed treatment which would warrant the use of psychotherapy to this degree. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pre-approve psychotherapy services.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay forthe continued SNF services from July 22, 2019 to July 30, 2019.You asked the Plan to pay forSNF care. You say that there was never a last covered day issued from the insurance company. You also say that the enrollee was still in need of therapy because they were experiencing redness and swelling at the site of her prosthetic site.The Plan denied your request. The Plan says that the appropriate care could have been provided at a lower level than inpatient SNF.The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal.We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before July 22, 2019. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued.The records show that the NOMNC provided to the enrollee says that the last covered day would be July 30, 2019. Therefore, we decided that the Plan has to pay forthe continued SNF services from July 22, 2019 to July 30, 2019.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case againif we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle Lite test strips.
You asked the Plan to pre-approve Freestyle Lite 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 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 Freestyle Lite test strips. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation in the medical records does not support that the plan's approved test strips, AccuCheck or OneTouch, would likely be less effective for you in this case. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Freestyle Lite test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle Lite test strips.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ExoDx Prostate testing provided to the enrollee on November 11, 2019.
You asked the Plan to pay for the testing services. You say that the analysis was critical in determining the appropriate treatment assessment for the enrollee. The Plan denied your request. The Plan says the testing is not listed as Medically necessary by Medicare or the enrollee's plan.
The Plan must follow Medicare rules. The rules also say that experimental and investigational devices are not covered. Medicare rules say that EPI biomarkers are deemed investigational.
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the ExoDx Prostate testing provided on November 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 9, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office visit. You say that you performed service assuming that authorization had been obtained. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the enrollee self-directed for service.
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 October 9, 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 hospital discharge day management services coded 99238You asked the Plan to pay for the hospital discharge day management services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.In this case, the CPT Code Manual definition of code 99238 is hospital discharge day management; 30 minutes or less.We find that CPT code 99238 is not supported in the medical record. Specifically, the documentation shows that the enrollee was admitted to the hospital on October 30, 2019 and discharged on November 6, 2019. Therefore, the enrollee was no longer in the hospital on November 7, 2019. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met.Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services coded 99238
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 4, 2019 by an
out of network (OON) provider.
You asked the Plan to pay for the external electrocardiographic recording (93226). You say that the member
followed policy guidelines by seeking the services of an in-plan provider who, during the course of the
treatment, ordered a procedure that was partially performed out-of-network. The Plan denied your request. The
Plan says the utilization of network providers is required unless the Plan pre-approves out-of-network services
in non-emergent situations.
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 November 4,
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 rest home visit provided on November 20, 2019 by an out of network (OON) provider.You asked the Plan to pay for the rest home visit. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services rendered are not a covered benefit.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 rest home visit provided on November 20, 2019 by an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you were told by the ambulance driver that if you were transported to the hospital, you would just be sent back home. You say that later you called for an ambulance again and were then transported to the hospital where you underwent surgery. You stated that the claim should be covered because you were admitted to the hospital within seven hours of the first call and ended up having surgery. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on November 4, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the Part B injection provided on November 13, 2019.You asked the Plan to reduce the coinsurance forthe Part B injection. You say that you have been charged less  in the past for the same injection. The Plan denied your request. The Plan says the claims for May 28, 2019 and August 20, 2019 were processed incorrectly and you will have no liability. 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 20% coinsurance for each in-network Medicare-covered Part B drugs obtained in a provider's office or outpatient setting after your yearly deductible is met. You have been asked to pay $134.82 which is 20% of the allowed amount for the Part B injection. The allowed amount is $674.09. ($674.09 x 20% = $134.82). The Part B 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 reduce the coinsurance for the Part B injection provided on November 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmology services provided on October 17, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the OON services. The Plan denied your request. The Plan says there is no network deficiency for these services, and alternate network providers were found.
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 services at issue. We found no exception that would require the Plan to pay for these OON services. Therefore, we decided that the Plan does not have to pay for the ophthalmology services provided on October 17, 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 office visit, comprehensive hearing test and ear microscopy exam provided on October 29, 2019.You asked the Plan to waive the copayment for the office visit, comprehensive hearing test and ear microscopy exam. You say that you were not informed you would have additional charges to pay. You say that you don't intend to give them more money.The Plan denied your request. The Plan says the copayments 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 $35 copayment for services obtained from an in-network specialist, a $10 copayment for each in-network, Medicare-covered exam and a $20 copayment for in-network, Medicare-covered non-radiological diagnostic services. You have been asked to pay a total of $65 for the office visit, comprehensive hearing test and ear microscopy exam. The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The comprehensive hearing test falls within the "Hearing Services" benefit category. The ear microscopy exam falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. 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 for the office visit, comprehensive hearing test and ear microscopy exam provided on October 29, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on December 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for lab work. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the provider should have verified the member's eligibility.
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 lab work provided on December 23, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to reduce the copayment forthe office visit provided on November 6, 2019.You asked the Plan to reduce the copayment forthe office visit. You say that you were told the visit was the same as an office call to your physician. You say you were told it would only be a $5 copayment. The Plan denied your request. The Plan says that 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. Your contract with the Plan says that enrollees must pay a $5 copayment for each in-network Medicare-covered visit with a PCP. The Plan says you must pay a $50 copayment for the office visit. Based on the Plan contract, however, you cannot be asked to pay more than a $5 copayment for the office visit. The record shows that an immediate care clinic is not considered a specialist's office. Therefore, we decided that the Plan has to reduce the copayment forthe office visit provided on November 6, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for a colonoscopy and specialist services provided on December 10, 2019.
You asked the Plan to waive the copayments for a colonoscopy and specialist services. You say that you feel that the colonoscopy was a screening and you should not be responsible for 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 $400 copayment for outpatient surgery services. Your contract with the Plan also clearly says that you must pay a $50 copayment for visits with a specialist. The medical records show that you had polyps removed during a colonoscopy on December 10, 2019. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $400 copayment for surgery services and a $50 copayment for specialist services. The total amount you owe is: $450. You have been asked to pay the total copayment amount of $450 for a colonoscopy and specialist services. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. A specialist 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 copayments for a colonoscopy and specialist services provided on December 10, 2019.