Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve your power mobility device repairs.You asked the Plan to pre-approve scooter repairs. You say that your scooter needs repairs or you cannot get outside for fresh air.The Plan denied your request. The Plan says there is no record of how old the scooter is or if you meet criteria for a scooter.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. The file does not show that you do have a mobility deficit that impairs your participation in MRADLs, your condition cannot be improved by a walker, cane or manual wheelchair, or that you can safely operate the PMD. This means that Medicare rules for coverage of a PMD have not been met.Therefore, we decided that the Plan does not have to pre-approve your power mobility device repairs.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on February 17, 2020.You asked the Plan to waive the copayment for the specialist office visit. You say that you should not be responsible for the copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules saya 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 $50 copayment for each specialist visit for Medicare-covered services. You have been asked to pay a $50 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including services provided at 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 copayment for the specialist office visit provided on February 17, 2020. Your complaint that you were unhappy with the doctor's examination is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on February 10, 2020.You asked the Plan to pay forthe shoulder-elbow-wrist-hand orthosis (L3960). You say that the orthosis was 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.The medical records provided do not mention the orthosis.Therefore, we decided that the Plan does not have to pay for the shoulder-elbow-wrist-hand orthosis provided on February 10, 2020
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 15, 2020 by an out of network (OON) provider.You asked the Plan to pay for the podiatry services. You say that you would like reconsideration because the facility sent the rendering provider.The Plan denied your request. The Plan says this provider is out-of-network and no prior authorization was requested to see this 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 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 a tissue. 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 January 15, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator provided to the enrollee on January 22, 2020 by an out of network (OON) provider.You asked the Plan to pay for the oxygen concentrator. You say that the enrollee did not notify you of any health plan changes.The Plan denied your request. The Plan says that this was not authorized by the Plan.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 oxygen concentrator provided to the enrollee on January 22, 2020 by an out of network (OON) provider.
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 you would like reconsideration because this drug is medically necessary for the treatment of the member's condition.The Plan denied your request. The Plan says the member has not met step-therapy exception criteria.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 provided medical records do not indicate that the member has tried and failed the required drugs. Our physician reviewer found the provided medical records do not indicate that the Plan's required drugs would likely be less effective and/or likely have adverse effects for the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Euflexxa have not been met.Therefore, we decided that the Plan does not have to pre-approve Euflexxa (J7323).
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pre-approve an Orthovisc injection.You asked the Plan to pre-approve the Orthovisc. You say that you would like reconsideration as this injection is medically necessary. The Plan denied your request. The Plan says that osteoarthritis is not shown on the imaging.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 the Orthovisc. Our reviewer says that the criteria has been met for a trial of viscosupplementation therapy (Orthovisc) for the knee.  Our physician reviewer found bilateral knee pain was reported which had failed conservative treatments including steroid injection, medication, and physical therapy.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 Orthovisc have been met. Therefore, we decided that the Plan has to pre-approve an Orthovisc injection. 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 must 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on December 9, 2019.You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says there is no authorization on file.Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.The requested provider in this case is not a network provider with the Plan. The Plan did not pre-approve the service 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 subsequent nursing facility care providedon December 9, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for medical eye examination  and evaluation (92012) deluxe frames (V2020) progressive lenses (V2871) polycarbonate lenses (V2784) and tint, photocromatic lenses (V2744) provided October 28, 2019.You asked the Plan to waive the copayment for the vision services. You say that the provider told you that they were a PPO provider. You had to pay the full amount of $504 and you do not have this kind of money to pay full cost.The Plan denied your request. The Plan says This claim was processed correctly and the correct cost share was 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 50% coinsurance for Medicare covered eye exam. The plan has a $250 eyewear allowance. The health plan contract says that if you use an out of network provider, your share of costs for your covered services may be higher.You have been asked to pay $219.50 for the vision services. Payment was issued in the amount of $284.50 (50% coinsurance for 92012) and $250 maximum allowance.The vision services fall within the Vision 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 medical eye examination  and evaluation (92012) deluxe frames (V2020) progressive lenses (V2871) polycarbonate lenses (V2784) and tint, photocromatic lenses (V2744) provided October 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Repatha Sureclick.You asked the Plan to pre-approve the Repatha Sureclick. You say that you would like reconsideration because this drug is medically necessary for the treatment of the member's condition.The Plan denied your request. The Plan says this drug is not covered for the member's condition by Medicare 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-approve the Repatha Sureclick.Benefits for the Repatha Sureclick 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the portable x-ray services (73660, Q0092, R0070) on January 16, 2020.You asked the Plan to pay for the portable x-ray services. You say that the services were medically necessary.The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were network providers available.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 portable x-ray services (73660, Q0092, R0070) on January 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic treatment provided on November 25, 2019.You asked the Plan to pay for the chiropractic treatment. You say that you have been going to this provider for over thirty years and you trust this provider for your care. The Plan denied your request. The Plan says you must receive care from in-network providers with the exception of emergency or urgent care, dialysis while temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which requires prior authorization from the plan. 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 chiropractic treatment. 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 chiropractic treatment provided on November 25, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on January 6, 2020.You asked 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 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 physician's services provided on January 6, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room services provided January 9, 2020.You asked the Plan to waive the copayment for the emergency room services. You say that the copayment should be waived.The Plan denied your request. The Plan says the correct copayment was 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 $75 copayment for Emergency Care. You have been asked to pay a $75 copayment for the emergency room services. The emergency room services 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 emergency room services provided January 9, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the oxygen concentrator (E1390) provided on February 15, 2020 by an out of network (OON) provider.You asked the Plan to pay for the oxygen concentrator. You say that the records should support the necessity of the service in dispute.The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-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 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 oxygen concentrator (E1390) provided on February 15, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on November 11, 2019.You asked the Plan to pay for the knee orthosis (L1833) and suspension sleeve (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says there is no claims history of evaluation and management services with the ordering physician.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. Documentation submitted did not contain evidence of a relationship with the ordering physician as required per CMS guidelines. Based on this information, we decided that Medicare rules for coverage of the knee orthosis (L1833) and suspension sleeve (L2397) have not been met.Therefore, we decided that the Plan does not have to pay for the knee orthosis and suspension sleeve provided on November 11, 2019.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a biological implant (15777-50-51) provided on November 16, 2018.You asked the Plan to pay for the biological implant. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that CPT code 15777-50-51 was billed with an invalid modifier.The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The surgeon is a Plan contract provider. The facility is not a Plan contract provider. The Plan states they reviewed medical records, but none were forwarded. The Plan is not clear in its explanation of the modifier issue on the claim itself. If ultimately the Plan is approving the service and only requires a corrected claim, that should be explained clearly in the case file. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to forward medical records or enough information so substantiate the denial of services. Therefore, we decided that the Plan has to pay for a biological implant (15777-50-51) provided on November 16, 2018. 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for spinal x-rays (72040, 72070 and Q0092) provided on December 20, 2019.You asked the Plan to pay for the spinal x-rays. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the services billed.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 pay for the spinal x-rays. Our reviewer says that the enrollee received x-rays of the entire spine on the same DOS. Rather than billing for each section of the spine separately (72040, 72070, 72100), the single code indicating that the entire spine was x-rayed (72085), should be used. Our physician reviewer found as the x-rays were taken at the same time, in the same place, only one set-up fee should be billed (Q0092).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).You asked the Plan to pre-approve the additional trips. You say that you are blind and will no longer have trips available needs and you are requesting additional trips.The Plan denied your request. The Plan says this request exceeds the benefit limit of 10.Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 10 trips per year. We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation.Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips (A0100).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for Cxbladder testing provided on October 29, 2019.You asked the Plan to pay for Cxbladder test. You say that you disagree with the Plan's denial for this test.The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this test is not covered by Medicare.Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The plan follows these rules.This testing was ordered by an in-network provider. The file does not show that the plan provided notice that Cxbladder test would not be covered. Under Medicare rules, this means Cxbladder test is considered approved by the plan.Therefore, we decided that the Plan has to pay for Cxbladder testing provided on October 29, 2019.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.