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

We decided that the Plan does not have to pre-approveHumira Inj 40/0.4 ML.You asked the Plan to pre-approveHumira. You say that you would like the plan toreconsider their denial.The Plan denied your request. The Plan says Humira is not covered under the enrollee's Medicare Part B benefit. The plan states the enrollee's prescription drug coverage is provided through Caremark.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-approveHumira Inj 40/0.4 ML.Benefits for Humiramay 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 pay forpercutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch (92928) with various laboratory services provided on August16, 2019 to August 17, 2019.You asked the Plan to pay forsurgery. You say that you were living in Tennessee for couple of months and went to have astress test done on August 12, 2019. The provider then set up an outpatient surgical procedure on August 16, 2019. You state that you were not aware that prior authorization was needed for an out of network provider as you considered these services as an urgent matter. 
You do not want these outpatient services applied to travel benefits.The Plan denied your request. The Plan says your records do not show a request for prior authorization for out-of-network care or that you were directed th eenrollee by a network provider for treatment. The Plan says that the claim they received from the facility was coded as an elective procedure and the planned surgery was not urgent or emergent. The Plan further says that any amounts over and beyond the Traveler benefit are the responsibility of the enrollee.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. The Plan states that your Traveler benefit coverage is $2,500 and as of thesedatesof service, your Traveler benefit coverage has been exhausted.The services were provided outside of the Plan's service area. This is why you were not eligible for out-of-area urgent care as the records shows that services were elective.The record also shows that the Plan requested but did not receive medical records. If the services were urgent, they didn't have medical records tocorroborate the billed services.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 forpercutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch (92928) with various laboratory services provided on August 16, 2019 to August 17, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forthe chronic care management services provided on May 20, 2019 and June 28, 2019.You asked the Plan to waive the copayments forthe chronic care management services. You say that you only saw your primary care doctor on April 29, 2019 and August 7, 2019.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 $15 copayment for each covered in-network primary care provider (PCP) office visit. You have been asked to pay a $15 copayment for each of the chronic care management services. The chronic care management services fall within the "Physician/Practitioner services, including doctor's office visits" benefit category. The medical record shows you received chronic care management services on May 20, 2019 and June 28, 2019.This means thatyou 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 forthe chronic care management services provided on May 20, 2019 and June 28, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the physician services rendered to you on September 16, 2019.

You asked the Plan to pay for these services. You say that the services should be covered because you moved out of the area. The Plan denied your request. The Plan says the services were not urgent or emergent and were rendered by an out-of-area provider without prior authorization.

Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  

We looked at the file and Medicare rules. The file shows that you moved outside of the Plan's service area. The services were with a primary care physician and were not for an unforeseen illness or injury. 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 physician services rendered to you on September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on July 3, 2019 by out of network provider.You asked the Plan to pay forthe laboratory services. 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 forthe laboratory services provided on July 3, 2019 by out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-ray (D0274) provided on August 13, 2019.You asked the Plan to pay forthe dental service. You say that you should not be liable for the services as you changed dental providers.The Plan denied your request. The Plan says the frequency limit for bitewing x-rays has been exceeded.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage and bitewings are listed as a covered service, the frequency limit has been exceeded. The record shows you last received bitewing x-rays on January 7, 2019.Therefore, we decided that the Plan does not have to pay forthe bitewing x-ray (D0274) provided on August 13, 2019
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on September 20,2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC.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 services.Therefore, we decided that the Plan does not have to pay forthe medical services provided by an out-of-network provider on September 20, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from August 2, 2019 to October 21, 2019.You asked the Plan to pay forthe glucose monitor (E0607), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim.The Plandenied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay forthe glucose monitor, test strips, lancets, control solution, and lancet device provided by "the provider" from August 2, 2019 to October 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient skilled nursing facility (SNF) services provided by out of network provider from April 1, 2019 to April 12, 2019.You asked the Plan to pay for these services. You say that you are requesting reconsideration of the plan's denial.The Plan denied your request. The Plan says non-emergent services were rendered by an out of network provider at a non-participating facility 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 and the facility in this case are not network providers with the Plan. The Plan has network providers available who can provide the servicesat 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 services.Therefore, we decided that the Plan does not have to pay forthe inpatient skilled nursing services(SNF)provided April 1, 2019to April 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora sleep study provided on June 3, 2019.You asked the Plan to waive the coinsurance fora sleep study. You say that you were not informed that you would owe a facility charge.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 20% coinsurance for sleep studies.You received a sleep study on June 3, 2019. The allowed amount is $941.71 and 20% of that is $188.34.  You have been asked to pay the total coinsurance amount of $188.34 for a sleep study. A sleep study falls within the outpatient diagnostic tests and therapeutic services 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 coinsurance fora sleep study on June 3, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvefoot orthotics.You asked the Plan to pre-approvefoot orthotics. You say that you need the requested orthotics because of the many forms of arthritis you have. You say that the requested orthotics will help with your pain and allow you to be more stable.The Plan denied your request. The Plan says this item is not a coveredbenefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay formammogram services (77063 and 77067) provided on November 12, 2018.You asked the Plan to pay for the mammogram. You say that these services have been reimbursed in the past. The Plan denied your request. The Plan says this service was rendered by a provider who is not under contract with the health plan and not certified for Medicare.The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.The services at issue in this appeal were provided in a non-urgent, non-emergent situation by Julie Mitnick, MD. This provider has opted out of the Medicare program. The file shows that the provider entered into a private contract with you regarding payment. Therefore, we decided that the Plan does not have to pay for mammogram services (77063 and 77067) provided on November 12, 2018.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the claim should be reprocessed.The Plandenied 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 July 18, 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 forthe ambulance services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran EGD provided on October 3, 2018.You asked the Plan to waive the copayment foran EGD. You say that you disagree with 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 $295 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You received an EGD on October 3, 2018. An EGD is considered an outpatient surgical procedure. Therefore, you are responsible to pay the $295 copayment. You have been asked to pay a $295 copayment for an EGD. An EGD 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 enrolledin the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran EGD provided on October 3, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe tubing extension kit and infection controlsupplies provided by "the provider" on July 17, 2019.You asked the Plan to pay forIV tubing extension kit(S1015) and infection control supplies (S8301). You say that the Plan should pay this claim.The Plan denied your request. The Plan says S codes are not payable by Medicare.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 S1015 is IV tubing extension kit and S8301 is Infection control supplies.We find that CPT code S1015 and S8301 are not valid codes for Medicare purposes. S codes are unique temporary codes established by BCBSA and HIAA for private payor use. They are not valid nor payable by Medicare. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of IV tubing extension kit(S1015) and infection control supplies (S8301) have not been met.Therefore, we decided that the Plan does not have to pay forthe IV tubing extension kit and infection control supplies provided by "the provider" on July 17, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory testing provided on July 1, 2019.You asked the Plan to waive the copayment forlab tests. You say that you have never been responsible for multiple copayments for laboratory work.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $10 copayment for in-network lab tests. You have been asked to pay $10 copayment for lab tests. Lab tests fall 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 copayment forlaboratory testing provided on July 1, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprovea pneumatic compression device (E0652).You asked the Plan to preapprovea pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules.The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At leastfour weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour 
home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprovea pneumatic compression device (E0652).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approveGroup 2 very heavy duty power wheelchair and accessories.You asked the Plan to pre-approveGroup 2 very heavy duty power wheelchair (K0827) and accessories. You say that the enrollee needs a Group 2 very heavy duty power wheelchair to complete MRADLs.The Plan denied your request. The Plan says criteria for a power wheelchair is not met.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 Group 2 very heavy duty power wheelchair and accessories. Our physician reviewer found the records do not indicate that a group 11 device or manual wheelchair, optimally-configured, could not safely and adequately address this member's needs.  As such, a group 2power mobility aid is at this time, not medically 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 Group 2 very heavy duty power wheelchair and accessories have not been met.Therefore, we decided that the Plan does not have to pre-approveGroup 2 very heavy duty power wheelchair and accessories
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the first intraoral periapical x-ray (code D0220) and bitewing x-ray (code D0270) provided on July 5, 2019.You asked the Plan to pay for the periapical x-ray and bitewing x-ray. You say that you lost a cap that was on the lower molar. You also say that you went to the dentist for an evaluation consultation to have the cap repaired.The Plan denied your request. The Plan says these services exceed the benefit allowance. The Plan also says that these services are allowed two times per calendar year. 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, preventative x-rays are limited to 2 per calendar year (either D0220, D0230, D0270, D0272, D0273, or D0274 per calendar year). The record shows that you received an additional intraoral periapical x-ray (code D0230) and bitewings (code D0274) on January 18, 2019 and your preventative x-rays benefit was then exhausted.Therefore, we decided that the Plan does not have to pay for the first intraoral periapical x-ray (code D0220) and bitewing x-ray (code D0270) provided on July 5, 2019.Your complaint about not knowing you needed a referral for the procedure and having to pay up front 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.