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

We decided that the Plan does not have to pay for a handheld shower holder & slider bar, and grab bars.
You asked the Plan to pay for a handheld shower holder & slider bar, and grab bars. You say that you needed
these items. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan covers all items that Medicare covers. Medicare rules state that a shower handle and grab bars are not
covered because they are not primarily medical in nature.
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item.
Therefore, we decided that the Plan does not have to pay for a handheld shower holder & slider bar, and grab
bars.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an office visit provided by an out-of-network provider on July 22, 2019
You asked the Plan to pay for an office visit. You say that you had a referral from your doctor to see this provider. The Plan denied your request. The Plan says that no prior authorization was obtained.
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 health plan follows these rules. You were referred for an office visit by a physician. The file does not show that the health plan provided enough information to determine the in-network status of the referring provider. Under Medicare rules, this means an office visit is considered approved by the health plan. Therefore, we decided that the Plan has to pay for an office visit provided by an out-of-network provider on July 22, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for an outpatient surgery provided by a participating hospital on April 5, 2018.
You asked the Plan to waive the coinsurance for an outpatient surgery. You say that you do not think it is fair to wait two years to send a bill. The Plan denied your request. The Plan says the correct coinsurance has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 25% coinsurance for outpatient surgery/in-network/outpatient hospital center. You have been asked to pay a 25% coinsurance of the allowed amount for an outpatient surgery. The total allowed amount is $3,179.50. The total amount you are being asked to pay is $303.01 ($1,212.02 x 25% = $303.01). An outpatient surgery falls within the outpatient surgery/in-network/outpatient hospital center 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 for an outpatient surgery provided by a participating hospital on April 5, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the MRI provided on February 5, 2020.
You asked the Plan to waive the copayment for the MRI. You say that you were only in the machine for 20 minutes and you cannot afford this 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 $175 copayment for each Medicare-covered advanced radiology service. You have been asked to pay $175 copayment for the MRI. The MRI falls 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 the MRI provided on February 5, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 15, 2019 by an out of network provider.
You asked the Plan to pay for compression stockings (A6549). You say that you attempt to get the stockings from an in network provider, and when you couldn't you got them from the provider. The Plan denied your request. The Plan says compression stockings are covered upon written prescription from a network physician to a network DME or Orthotics and Prosthetics (O&P) supplier in your PCP's referral circle. the provider is not a DME supplier within the Health Plan Network, so the Plan has denied the 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 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 May 15, 2019 by an out of network provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nasal endoscopy provided on January
13, 2020.
You asked the Plan to waive the copayment for the nasal endoscopy. You say that this service was medically
necessary follow-up and you should not be charged for the service. 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 $50
copayment for a specialty physician for other Medicare-covered outpatient diagnostic tests.
You have been asked to pay a $50 copayment for the nasal endoscopy. The nasal endoscopy falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Please note, there is no
provision in the contract which indicates a copayment would be waived if performed as a follow-up service.
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 nasal endoscopy provided on January 13, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on November 19,
2019.
You asked the Plan to pay for the dental service. You say that the dental office gave you the wrong x-rays. The
Plan denied your request. The Plan says bitewing x-rays are not a covered service.
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 bitewing x-rays are not among
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the bitewing xrays
(D0274) provided on November 19, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a permanent cardiac contractility modulation system.
You asked the Plan to pre-approve the requested services. You say that the enrollee has failed conservative treatment. The Plan denied your request. The Plan says the requested service is not covered because it is not proven effective.
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. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a permanent cardiac contractility modulation system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an insulin pump provided by an out-of-network provider on December 28, 2018.
You asked the Plan to waive the deductible for an insulin pump. You say that you did not know this was an out-of-network provider. The Plan denied your request. The Plan says the correct deductible amount has been applied.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible for what is your plan deductible and durable medical equipment/out-of-network. The item or service you asked the Plan to waive the deductible for falls within the benefit category what is your plan deductible and durable medical equipment/out-of-network. The total amount you are being asked to pay is $339.94. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for what is your plan deductible and durable medical equipment/out-of-network. This cost sharing is a contractual obligation that had not been met at the time an insulin pump was received on December 28, 2018. Therefore, we decided that the Plan does not have to waive the deductible for an insulin pump provided by an out-of-network provider on December 28, 2018.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram provided on July 26, 2019.
You asked the Plan to waive the copayment for the mammogram. You say that you had breast cancer in 2016 and your doctor says you must have a mammogram every six months. 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 $75 copayment for each Medicare-covered radiological diagnostic service, not including x-rays, performed in a physician's office or at a free-standing facility. You have been asked to pay a $75 copayment for the mammogram. The mammogram falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" benefit category. The record shows you have a history of breast cancer which makes the mammogram diagnostic 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 mammogram provided on July 26, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (CPT 73580, CPT 27369, CPT 99212 and HCPCS J7320) provided to the enrollee on November 18, 2019.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says these services are not supported without the required documentation.
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 the denied codes is: CPT 99212: Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family. CPT 27369: Injection procedure for contrast knee arthrography or contrast enhanced CT/MRI knee arthrography. CPT 73580: Radiologic examination, knee, arthrography, radiological supervision and interpretation. HCPCS J7320: Hyaluronan or derivitive, Genvisc 850, for intra-articular injection, 1 mg We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the documentation submitted was reviewed and does not support CPT 99212-25, this code is included in global day period, and no documentation supports modifier 25 a significant, separately identifiable evaluation and management service. The docuemntation submitted was reviewed and HCPCs code J7320 Hyaluronan or derivative, genvisc 850, for intra-articular injection, 1 mg is not documented as given in this case. The documentation submitted was reviewed, and did not contain evidence of radiologic examination and interpretation (CPT 73580). The documentation submitted was reviewed, and the records did not contain radiology and interpretation report to support CPT 27369 Injection procedure for contrast knee arthrography or contrast enchanced CT/MRI knee arthrography. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for physician services (CPT 73580, CPT 27369, CPT 99212 and HCPCS J7320) provided to the enrollee on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a specialist office visit provided on August 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for medical visits. You say that you are asking for reimbursement for the specialist visit. The Plan denied your request. The Plan says no prior authorization was obtained.
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 a specialist office visit provided on August 23, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve a Freestyle Libre CGM. You say that the enrollee has requested this item. The Plan denied your request. The Plan says the enrollee does not meet criteria for coverage of this item.
The Plan must follow Medicare rules. Medicare rules say that CGMs are only covered for enrollees who have diabetes mellitus and are insulin-treated with multiple daily injections of insulin. We looked at the file and Medicare rules. The record shows that the enrollee does not have diabetes mellitus and is not insulin-treated. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Brovana.
You asked the Plan to pre-approve Brovana. The Plan denied your request. The Plan says the enrollee has not had previous treatment, contraindication, or intolerance to Perforomist (formoterol).
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 Brovana. Our physician reviewer found that the enrollee has chronic obstructive pulmonary disease with acute exacerbation, and a pleural plaque. The Plan requires a trial of Perforomist before they will approve the requested drug. The documentation does not show that the enrollee has tried and failed the required drug. The documentation does not support that Perforomist would likely be less effective, or would 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 Brovana have not been met. Therefore, we decided that the Plan does not have to pre-approve Brovana.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 23, 2019 by an out of network (OON) provider.
You asked the Plan to pay for sleep study. You say that you are appealing. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider is out-of-network with the Plan and the referring provider is also out-of-network with 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 medical services provided on April 23, 2019 by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Herceptin for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says no new documentation was received changing the current information.
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found a request for Herceptin was made intended to be used in conjunction with PERJETA and Docetaxel. This drug combination regimen is an off-label use of Herceptin. Herceptin is currently only FDA-approved for treating metastatic breast cancer for those with HER2 overexpressed tumors who have received chemotherapy or in combination with chemotherapy. There is evidence to support the use of Herceptin for metastatic gastroesophageal adenocarcinoma with HER2 overexpressed tumors but only in combination with cisplatin and capecitabine or 5-fluoruracil. A search for any recent evidence for the use of PERJETA and Docetaxel along with Herceptin in the setting of metastatic gastroesophageal adenocarcinoma did not show sufficient support for this regimen. There was no provided information which might justify the use of Herceptin in this clinical situation. Therefore, this request for Herceptin will be considered not medically necessary at this time. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Herceptin for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair, accessories, and power tilt and recline.
You asked the Plan to pre-approve a Group 3 power wheelchair, accessories, and power tilt and recline. You say that the enrollee would benefit from a tilt and recline positioning system. The Plan denied your request. The Plan says the power wheelchair exceeds the enrollee's needs.
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 a Group 3 power wheelchair, accessories, and power tilt and recline. Our reviewer says that the power tilt and recline is not medically necessary. Our physician reviewer found the enrollee does not meet the requirement for power tilt and recline (E1007) per Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). The documentation indicates that the enrollee can independently transfer and can stand independently for 3-5 minutes before needing to sit down. The enrollee can sit in and get up from a chair. The documentation does not support that the enrollee is unable to perform a functional weight shift. The enrollee does not use intermittent catheterization for bladder management. The documentation does not reveal evidence of increased tone or spasticity. The request for a Group 3 power wheelchair with power tilt and recline is not medically necessary as these items on the wheelchair exceed the enrollee's medical need. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Group 3 power wheelchair, accessories, and power tilt and recline have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair, accessories, and power tilt and recline.