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

We decided that the Plan does not have to waive the copayment for laboratory services provided on July 25, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that the laboratory services should be considered preventative and have no copayment. 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 $0 copayment for laboratory tests provided by a Tier 1 provider and a $20 copayment when provided by a Tier 2 provider. You received laboratory services from a Tier 2 provider on July 25, 2019. Therefore, you are responsible to pay the $20 copayment. You have been asked to pay a $20 copayment for laboratory services. Laboratory services 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 for laboratory services provided on July 25, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe two additional extractions and first intraoral periapical x-ray provided from June 24, 2019 to August 20, 2019.You asked the Plan to pay forthe two additional extractions and first intraoral periapical x-ray. You say that you told your dentist that your insurance would not pay for 4 extractions. You also say that this provider told you not to worry, and that they would take care of it.The Plan denied your request. The Plan says benefits for the additional extractions had been satisfied and the frequency limitation had been exceeded.Medicare generally does not coverdental 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, extractions are limited to two procedures per calendar year. The record shows that you received four extractions on June 24, 2019, two of which were paid for by the Plan at the in-network rate, and your extractions benefit had been exhausted.The record also shows that you received additional intraoral periapical x-rays on July 26, 2019 and your intraoral x-rays benefit was then exhausted.Therefore, we decided that the Plan does not have to pay forthe two additionalextractionsandfirst intraoral periapical x-ray provided from June 24, 2019 to August 20, 2019
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869).You asked the Plan to pre-approvethe Vertiflex Superion device. You say that the member has spinal stenosis and has failed conservative measures. The Plan denied your request. The Plan says the FDA approval criteria and Guideline states that a body mass index (BMI) of 40 or more is a contraindication to the VertiFlex Superion device.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the device is experimental and more research is needed to show its safety and efficacy.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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device (22869).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided on August 23, 2018. You asked the Plan to pay for the ambulance services. You say that the Plan should pay this claim The Plan denied your request. The Plan says the claim was filed untimely. The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service. The record shows that a claim for the ambulance services was not filed until October 23, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for services provided on August 23, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on September 17, 2019 by an out of network (OON) 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 September 17, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the medical eye exam provided on
November 12, 2019.
You asked the Plan to waive the copayment for the medical eye exam. You say that you were told by the
people in the office that there would be a $0 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 $35
copayment for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an
annual glaucoma screening for members at high risk.
You have been asked to pay a $35 copayment for the medical eye exam. The medical eye exam falls within the
"Vision care" benefit category. The record shows a diagnosis of cataracts, which makes the 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 November 12, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.You asked the Plan to pre-approve SNF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewerto 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are skilled needs, but they do not need to be provided on a daily basis. Your care can be appropriately managed at a custodial level with intermittent skilled services on a less than daily basis and a periodic reassessment of your condition.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care provided on October 14, 2019.
You asked the Plan to pay for the subsequent nursing facility care. 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 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 provided on October 14, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on October 21, 2019.You asked the Plan to pay for the topical application of fluoride varnish. You say that one of the benefits included in your dental package is two fluoride treatments. You also say that you have asked the provider to change the code, but they are unable to do so.The Plan denied your request. The Plan says this service is not covered by your plan.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, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pay for the topical application of fluoride varnish (D1206) provided on October 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab work provided on September 23, 2019 by an out of network (OON) provider.You asked the Plan to pay forlab work. You say that these lab tests were referred by a physician. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the referring provider is also out-of-network.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 forlab work provided on September 23, 2019 by an out of network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF admission.You asked the Plan to pre-approve the SNF admission. You say that the SNF admission is medically necessary. The Plan denied your request. The Plan says the request SNF services are not medically necessary because the member requires continued weaning by pulmonology.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the member does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 SNF admission have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF admission.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cologuard test (81528).You asked the Plan to pre-approve the Cologuard test. You say that the member needs to have the scheduled repeat colonoscopy but cannot undergo any procedure with anesthesia or sedation. The Plan denied your request. The Plan says the member has a history of adenomatous polyps and as such is not at average risk.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the Cologuard test. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found given the low sensitivity of Cologuard in detecting adenomas, and the fact that the member is at increased risk of adenomas by virtue of past history, Cologuard does not meet criteria for coverage in this case nor is it an appropriate substitution for colonoscopic adenoma resurveillance.None of member's multiple co-morbidities disqualify him for a well-prepped colonoscopy with monitored anesthesia. 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 Cologuard test have not been met. Therefore, we decided that the Plan does not have to pre-approve a Cologuard test (81528).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic exercises provided on July 17, 2019.You asked the Plan to pay for the therapeutic exercises. 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 services at issue. We found no exception that would require thePlan to pay for these services. Therefore, we decided that the Plan does not have to pay for therapeutic exercises provided on July 17, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from October 5, 2019 to October 30, 2019. You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) level of care. The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. 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 skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from October 5, 2019 to October 30, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aids provided October 15, 2019.You asked the Plan to pay for the hearing aids. You say that the records provided should support the necessity of the services in dispute.The Plan denied your request. The Plan says the records do not support the service billed.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 physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid physician order, an itemized shipping/billing invoice to indicate the specific supplies or a proof of deliver for the supplies provided in this case. The delivery date shows as 11/07/2019 which would be the billed date of service when not using a third party delivery service.Therefore, we decided that the Plan does not have to pay for the hearing aids provided October 15, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for routine eye exam (92014) and retinal photos (92134) provided October 25, 2019.
You asked the Plan to pay for the vision services. You say that your plan is a PPO and you have provided an updated invoice with additional information and the invoice shows that you have paid the total at the time of your visit. The Plan denied your request. The Plan says routine eye exams are allowed once a year and retinal photos is not a covered benefit.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers these services when 1 routine eye exam a year.. We looked at the file and the Plan's rules. routine eye exams are allowed once a year and retinal photos is not a covered benefit. Based on this information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, we decided that the Plan does not have to pay for routine eye exam (92014) and retinal photos (92134) provided October 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hemoglobin; glycosylated (A1C) testing provided to the enrollee on October 15, 2019.You asked the Plan to pay for the testing. You say that this is medically necessary.The Plan denied your request. The Plan says Medicare says that tests with no relation to a diagnosis for the health of the patient are not a benefit.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 testing. Our reviewer says that the testing at issue in this case is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided the enrollee does not meet the criteria for glycosylated hemoglobin (A1C) testing.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 testing have not been met.Therefore, we decided that the Plan does not have to pay for hemoglobin; glycosylated (A1C) testing provided to the enrollee on October 15, 2019.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Eylea.
You asked the Plan to pre-approve Eylea. You say that you are appealing with records. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Bevacizumab before it will approve Eylea.
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 Eylea. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Eylea. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drug of Bevacizumab. The documentation does not support that Bevacizumab would likely be less effective and/or 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 Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Eylea.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on July 2, 2019.
You asked the Plan to pay for train of four testing. You say that this was medically necessary. The Plan denied your request. The Plan says payment of this service is bundled into other services.
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 95999 is not supported in the medical record. Specifically, the use of unlisted CPT code 95999 to report train of four testing is not supported. According to CPT coding rules, train of four testing is not a separately reportable procedure and is included in the other interoperative neuromonitoring procedures. Based on this information, we decided that Medicare rules for coverage of train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for train of four testing (95999) provided on July 2, 2019.