Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on October 1, 2019.
You asked the Plan to waive the copayment for the medical eye exam. You say that you had a routine eye exam and should not be charged a copayment. 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 $40 copayment for each in-network Medicare-covered exam to treat an eye condition. You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows diagnosis codes for age-related cataracts and nystagmus which makes the eye exam medical in nature.
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 medical eye exam provided on October 1, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Toviaz for the enrollee.
You asked the Plan to pre-approve Toviaz. You say that the medication has been helping control the enrollee's symptoms. The Plan denied your request. The Plan says the enrollee's medical plan does not cover outpatient prescription drugs.
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 Toviaz for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on September 17, 2019.
You asked the Plan to waive the copayment for the medical eye exam. You say that you had a routine eye exam and should not be charged a copayment. 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 $40 copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye, including an annual glaucoma screening for members at high risk. You have been asked to pay a $40 copayment for the medical eye exam. The medical eye exam falls within the "Vision care" benefit category. The record shows a diagnosis of age-related cataracts which makes the eye exam medical in nature.
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 medical eye exam provided on September 17, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Januvia for the enrollee.You asked the Plan to pre-approveJanuvia. You say that the enrollee would benefit from this medication.The Plan denied your request. The Plan says that this is not covered under Part B.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-approveJanuvia for the enrollee.Benefits for Januviamay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Dynamic Response Tri-planar brace provided on March 14, 2019 by out of network provider.
You asked the Plan to reimburse you for the custom made ankle knee orthotic brace. You say that you lost weight and the in-network provider would not be able to provide a bracing solution for you. The Plan denied your request. The Plan says you did not have 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 reimburse you 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 item at issue in this appeal. The Plan did not pre-approve the item at issue. We found no exception that would require the Plan to reimburse you for this item. Therefore, we decided that the Plan does not have to reimburse you for the Dynamic Response Tri-planar brace provided on March 14, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to you by an out-of-network provider on February 1, 2019.
You asked the Plan to pay for the services. You say that this should have been covered. The Plan denied your request. The Plan says out-of-network services are not covered.
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 for the medical services provided to you by an out-of-network provider on February 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided by an out-of-network provider on August 13, 2019.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says there is no network deficiency for these services.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who canprovide 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 August 13, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for definitive drug testing (G0483, 84228, 82542 and 80307) provided to the enrollee on August 19, 2019.You asked the Plan to pay forthis testing. You say that this claim should be paid.The Plan denied your request. The Plan says Medicare coverage criteria were not met.The Plan must follow Medicare rules. Medicare has specific documentation requirements for this type of testing. The physicians order and the medical records must specifically show how this testing will be used to treat illness or disease present in the enrollee at the time of service as opposed to this testing being done for screening purposes. Based on the records provided, the required Medicare criteria are not met. Therefore, we decided that the Plan does not have to pay fordefinitive drug testing (G0483, 84228, 82542 and 80307) provided to the enrollee on August 19, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on November 19, 2018 by an out-of-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services were 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 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 19, 2018 by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided from June 6, 2019 to June 20, 2019.
You asked the Plan to pay for extraspinal chiropractic manipulation. You say that the enrollee required this treatment. The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for extraspinal chiropractic manipulation (98943) provided from June 6, 2019 to June 20, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc injections.
You asked the Plan to pre-approve the Synvisc. You say that it is not reasonable to require the enrollee to try a different drug when he has had a previous positive response to Synvisc. The Plan denied your request. The Plan says regardless of response to another non-preferred drug, there was no failure of either of the preferred drugs.
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 Synvisc. Our reviewer says that the requested medication is not considered medically necessary based on step therapy criteria. Our physician reviewer found the enrollee has a diagnosis of Unilateral primary osteoarthritis of the right knee. It is noted that previous Synvisc-One injection was done on 8/14/18, and that the enrollee has had an excellent response to prior injections of Synvisc. There has been no trial of the plan preferred drugs. The documentation does not support that Orthovisc and Monovisc 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 the Synvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc injections.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to an out-of-network provider.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansayscare must be received from a network provider.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 pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plandoes not haveto pre-approvea referral to an out-of-network provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76770) provided on September 1, 2019.
You asked the Plan to pay for the ultrasound. You say that the member received multiple services on the same
day. The Plan denied your request. The Plan says 76770, was denied because it is a column II procedure to the
column I procedure, 93976.
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, we have confirmed that code the
ultrasound has a bundled relationship with code 93976 and cannot be paid as billed. This code cannot be paid
as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore,
we decided that the Plan does not have to pay for an ultrasound (76770) provided on September 1, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forgenetic testing ordered out of network and provided out of network on July 17, 2019.You asked the Plan to pay forout of network providers. You say that this testing should be covered by the Plan.The Plandenied your request. The Plan says you were aware of the need for prior authorization and chose to have the testing without the Plans approval.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan mustpay 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 networkproviders 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 forgenetic testing ordered out of network and provided out of network on July 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe paring or cutting of benign hyperkeratotic lesions (11055)provided to you on August 15, 2019.You asked the Plan to pay forthese services.You say that the services were necessary as the lesions were very painful to walk on and could have been infected and caused a more serious situation.The Plan denied your request. The Plan says the claim was paid less the excluded foot care provided during the office visit. There is limited coverage provided for routine foot care according to Medicare guidelines. The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation inthe legs or feet or have fungal nails. Records do not show that any of these conditions are present. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of these services have not been met.Therefore, we decided that the Plan does not have to pay forthe paring or cutting of benign hyperkeratotic lesions (11055) provided on August 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Computed Tomography Angiography (CTA) scan.You asked the Plan to pre-approveCTA scan. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for the requested CTA scan is correct, because a similar test has been done with results and repeat imaging is not supported without results showing a clear need for it.The Plan must follow Medicare rules. Medicare rules say that CT scans 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 CTA scan. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested CTA scan. Our physician reviewer found there is nothing in the documentation that the provider is aware that there was a recent Magnetic Resonance Angiography (MRA) test demonstrating high grade stenosis with post-stenotic dilatation. It is possible that this information would be enough of a positive non-invasive test with which to consider diagnostic angiography. However, coverage would at least require that the provider review the MRA results and indicate that the requested CTA is still necessary for specific reasons.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CTA scan have not been met.Therefore, we decided that the Plan does not have to pre-approvea Computed Tomography Angiography (CTA) scan.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ED visit provided on June 27, 2019.
You asked the Plan to waive the copayment for the ED visit. You say that this treatment was needed as a result of a failed CT scan. You say that you should not be responsible for payment. The Plan denied your request. The Plan says the copayment 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 $90 copayment for emergency services in an emergency room. You have been asked to pay a $90 copayment for the ED visit. The ED visit falls within the "Emergency care" 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 the ED visit provided on June 27, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle/foot orthoses provided to the enrollee on April 2, 2019.
You asked the Plan to pay for the orthoses. You say that these items were medically necessary. The Plan denied your request. The Plan says that your request is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an authorized originating site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located in a rural census tract. A review of the file does not show that the telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that the Plan does not have to pay for the ankle/foot orthoses provided to the enrollee on April 2, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for bilateral wrist-hand orthoses (L3916) provided to the
enrollee on September 13, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your
request. The Plan says the documentation does not indicate services are necessary for treatment of the
enrollee's condition.
The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services,
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for
telehealth services only if they are presented from an authorized originating site located in either a county
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located
in a rural census tract.
A review of the file does not show that the telehealth service was provided in an authorized originating site.
This means that the telehealth visit is not a covered service under the Medicare program and cannot substitute
for an in-person encounter. Consequently, the items/services ordered following the noncovered visit are
likewise noncovered. Therefore, we decided that the Plan does not have to pay for bilateral wrist-hand orthoses
(L3916) provided to the enrollee on September 13, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on September 30, 2019.Youasked the Plan to pay for the physician's services. The Plan denied your request. The Plan says non-emergent, non-urgent services with out-of-network providers require prior authorization.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the servicesat issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for physician's services provided on September 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 13, 2019 by an
out-of-network provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-participating 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 requested provider in this case is not a network provider with the Plan. The referring provider 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 September 13, 2019 by an out-of-network provider.