Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided by a provider that does
not participate in Medicare from October 13, 2019 to November 23, 2019.
You asked the Plan to pay for home health care services. You say that this should be covered. The Plan denied
your request. The Plan says the provider in question does not participate in Medicare.
The Plan must follow Medicare rules. Medicare rules say that home health services are covered only when the
home health agency that is providing the services to the beneficiary has in effect a valid agreement to
participate in the Medicare program
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of home health care services have not been met. The provider the enrollee received these services
from does not participate in the Medicare program. Therefore, we decided that the Plan does not have to pay
for home health care services provided by a provider that does not participate in Medicare from October 13,
2019 to November 23, 2019.
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 are appealing the Plan's denial of payment. You say that you have referred to your member handbook and given the circumstances, the Plan should provide coverage. You say that you did have ambulance transport services on August 10, 2019. 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 August 8, 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: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a kidney transplant.
You asked the Plan to pre-approve a kidney transplant. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 a kidney transplant. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the decision of transplant suitability is typically ceded to the transplant center. The questions that were brought up such as cardiac history and caregiver issues will be addressed by the transplant center who is qualified and able to properly ascertain and evaluate transplant suitability. This enrollee is suitable for evaluation for kidney transplant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a kidney transplant have been met. Therefore, we decided that the Plan has to pre-approve a kidney transplant.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for eye surgery (66821) provided on December 11, 2019.
You asked the Plan to waive the copayment for eye surgery. You say that this should be covered in full because it was a mandatory service. The Plan denied your request. The Plan says this processed 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 $175 copayment for each Medicare-covered ambulatory surgical center visit. You have been asked to pay a $175 copayment for eye surgery. This service was provided in an ambulatory surgical center. 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 eye surgery (66821) provided on December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist office visit provided by a participating provider on December 29, 2019.
You asked the Plan to waive the copayment for a specialist office visit. You say that you feel like the doctor didn't do anything. You say that you do not think this warrants a $35 copayment. The Plan denied your request. The Plan says 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 clearly says that you must pay a $35 copayment for physician/practitioner services/specialist visit. You have been asked to pay a $35 copayment for a specialist office visit. Since a specialist office visit was provided, the correct copayment has been applied. A specialist office visit falls within the physician/practitioner services/specialist visit 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 a specialist office visit provided by a participating provider on December 29, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay additionally for the ambulance services provided on July 26, 2019.You asked the Plan to pay additionally for the ambulance services. You say that you would like the Plan to reconsider their denial of payment.The Plan denied your request. The Plan says additional payment cannot be made.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.We looked at the file and Medicare rules. Medicare does not make payment for covered items or services to the extent that payment has been made, or can reasonably be expected to be made under a liability insurance policy or plan. Under certain circumstances, Medicare may make conditional payments if the liability insurance will not pay or will not pay promptly. As a Medicare secondary payer, a benefit is payable when the primary insurance payer's calculated amount is less than the Medicare allowed rates for the service. The file shows the enrollee's primary insurer's payment of $548 is higher than the Medicare allowable fee maximum of $468.34. The Plan denied the claim correctly.Therefore, we decided that the Plan does not have to pay additionally for the ambulance services provided on July 26, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral evaluation and dental implant to be performed by a prosthodontist.
You asked the Plan to pre-approve the dental services. You say that you have a hole where food gets stuck and is later discharged through your nose and the only way to correct this is to get a dental implant. The Plan denied your request. The Plan says this service is not a covered benefit. Dental services are only covered when performed by a participating general dentist.
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. The health plan contract also says that dental services are only covered when performed by a participating general dentist. 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 pre-approve an oral evaluation and dental implant to be performed by a prosthodontist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for lab work provided by a participating provider on January 10, 2020.
You asked the Plan to waive the copayment for lab work. You say that this should have been covered with your office visit. The Plan denied your request. The Plan says 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 clearly says that you must pay a $10 copayment for outpatient diagnostic tests/lab tests. You have been asked to pay a $10 copayment for lab work. The correct copayment has been applied to the services that were provided. Lab work falls within the outpatient diagnostic tests/lab tests 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 lab work provided by a participating provider on January 10, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wrist hand orthoses provided on December 19, 2019.You asked the Plan to pay for the wrist hand orthoses (L3916). You say that the orthoses were medically necessary The Plan denied your request. The Plan says the documentation submitted did not indicate the provider discussed the need for the billed supply codes, therefore the billed supply codes cannot be verified. The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The medical records do not mention or support medical necessity for the orthoses. Based on this information, we decided that Medicare rules for coverage of the wrist hand orthoses (L3916) have not been met.Therefore, we decided that the Plan does not have to pay for the wrist hand orthoses provided on December 19, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aimovig 140mg/ml autoinjector.
You asked the Plan to pre-approve Aimovig 140mg/ml autoinjector. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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-approve Aimovig 140mg/ml autoinjector.
Benefits for Aimovig 140mg/ml autoinjector may be available under Medicare Part D. Contact the 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 injection (S0020) provided on December 27, 2019. You asked the Plan to pay for an injection. You say that the records support this code. The Plan denied your request. The Plan says this code is not valid for Medicare purposes. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code S0020 is not supported in the medical record. Specifically, this code has a status indicator of "I." Medicare uses another code for reporting of, and payment for these services. Based on this information, we decided that Medicare rules for coverage of an injection have not been met. Therefore, we decided that the Plan does not have to pay for an injection (S0020) provided on December 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift mechanism (E0627).
You asked the Plan to pre-approve a seat lift mechanism. You say that the item is 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 a seat lift mechanism is covered if all of the conditions listed above are met. 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 a seat lift mechanism. Our reviewer says that the item is not medically necessary. Our physician reviewer found the enrollee's ability to transition from a seated to standing position in the home is not documented. A home assessment to determine whether the enrollee's seat height can be adjusted or is appropriate as well as her ability to transition independently would be required in order to support medical necessity for a seat lift. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism (E0627).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an injection provided by a participating provider on August 29, 2019 to December 10, 2019.
You asked the Plan to waive the copayment for an injection. You say that you have never had to pay a copayment for this before. The Plan denied your request. The Plan says the correct copayments 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 clearly says that you must pay a $40 copayment for physician/practitioner services/specialist. You have been asked to pay a $40 copayment for an injection. The total amount you are being asked to pay is $160 ($40 x 4 visits = $160). Since specialist services were provided, the correct copayments have been applied. An injection falls within the physician/practitioner services/specialist 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 an injection provided by a participating provider on August 29, 2019 to December 10, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.You asked the Plan to pre-approve these services. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has beck pain radiating to the upper extremity for several weeks. Physical examination reveals normal motor strength and reflexes with no upper motor neuron signs. There has not been any treatment thus far. There are no red flags findings and no conservative course of treatment has been implemented. The requested MRI is not medically reasonable and necessary.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 pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia (J0897).You asked the Plan to pre-approve Prolia. You say that the medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.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 Prolia. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the documentation does not support that Zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee 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 Prolia have not been met.Therefore, we decided that the Plan does not have to pre-approve Prolia (J0897)
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 88321) provided on September 6, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not payable in a facility setting.
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility or hospital for services furnished to a beneficiary. The facility or hospital must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. Payment for all fees related to this service would have been included under the facility claim. Therefore,
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient lab work provided by a participating provider on November 25, 2019 to December 17, 2019.You asked the Plan to waive the copayment for outpatient lab work. You say that you should only owe $30 for the last two visits. The Plan denied your request. The Plan says the correct copayments have 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 clearly says that you must pay a $15 copayment for outpatient diagnostic tests/laboratory tests. You have been asked to pay a total of $50.37 ($15 + $15 + $11.74 + $8.63 = $50.37) for outpatient lab work. outpatient lab work falls within the outpatient diagnostic tests/laboratory tests 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 outpatient lab work provided by a participating provider on November 25, 2019 to December 17, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve travel and lodging expenses for the services.
You asked the Plan to pre-approve travel and lodging expenses. You say that for treatment you need to be close to the facility. The Plan denied your request. The Plan says the facility is within 100 miles of your home.
The Plan must follow Medicare rules. Medicare rules say that a distant location is a location outside the normal community pattern of care. We looked at the file and Medicare rules. This facility is the closest Medicare facility that can provide the service and therefore is in the normal community pattern of care. Based on this information, we decided that Medicare rules for coverage of travel and lodging expenses have not been met. Therefore, we decided that the Plan does not have to pre-approve travel and lodging expenses for the services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on December 28, 2019 through December 29, 2019.
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration because these medically necessary services were rendered in good faith. The Plan denied your request. The Plan says the member's care did not meet medical necessity criteria for acute inpatient hospital care.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the member's necessary hospital care (including earlier ED and/or observation care) would span two midnights.