Persius/hicric huggingface dataset:
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of Zarxio.
You asked the Plan to pre-approve Zarxio. 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 Neupogen or Nivestim before it will approve Zarxio.
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 Zarxio. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Zarxio. Our physician reviewer found the enrollee has not tried the Plan's preferred drugs of Neupogen or Nivestym. The documentation does not support that Neupogen or Nivestym would likely be less effective and/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 Zarxio have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Zarxio.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe ankle foot brace provided on May 2, 2019.You asked the Plan to waive the coinsurance forthe ankle foot brace. You say that you were informed the Plan would cover the brace. You say that you declined the brace unless it was paid for by the Plan.The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for durable medical equipment.You have been asked to pay $108.31, which is 20% of the allowed amount for the ankle foot brace. The allowed amount is $541.56 (20% x $541.56 = $108.31). The ankle foot brace falls within the "Durable medical equipment (DME) and related supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the coinsurance forthe ankle foot brace provided on May 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an EGD provided on October 6,2019.You asked the Plan to waive the copayment for an EGD. You say that you thought that the EGD would be covered as preventative.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 $255 copayment for outpatient surgery services provided at ambulatory surgical centers.You received an EGD at an ambulatory surgical center on October 6, 2019. An EGD is considered an outpatient surgical procedure and is not a preventative service. Therefore, you are responsible to pay the $255 copayment.  You have been asked to pay a $255 copayment for an EGD. An EGD falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment for an EGD provided on October 6, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional physical therapy visits (G0151).
You asked the Plan to pre-approve the additional physical therapy visits. You say that the member needs help
with balance and is afraid of falling. The Plan denied your request. The Plan says physical therapy services
were authorized but not rendered by the home health agency in a timely manner.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for
home health care services.
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 additional physical therapy visits.
Our reviewer says that the records do not show further decline in functional or medical status or care plan to
warrant additional skilled physical therapy visits. Our physician reviewer found additional physical therapy
visits are not required to effectively provide treatment, care, and/or services which are medically necessary for
the member.
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 additional physical therapy visits have not been met. Therefore, we decided
that the Plan does not have to pre-approve additional physical therapy visits (G0151).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram (93010) provided on October 11, 2018.
You asked the Plan to pay for the electrocardiogram. You say that this is not a duplicate claim. The Plan denied
your request. The Plan says a claim for this date of service provided by the same provider was already
processed and paid.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the electrocardiogram have not been met. Specifically, the record indicates that a claim for the
same enrollee, provider, service and date of service has previously been processed and paid. Therefore, we
decided that the Plan does not have to pay for an electrocardiogram (93010) provided on October 11, 2018.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on July 16, 2019.
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you should only owe a $10 copayment and disagree with the additional charges. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 15% coinsurance for Medicare Part B prescription drugs. The medical records show that you received a Medicare Part B drug on July 16, 2019. The allowed amount is $537.36 and 15% of that is $80.60. You have been asked to pay the total coinsurance amount of $80.60 for a Medicare Part B drug injection. A Medicare Part B drug injection falls within the Medicare Part B prescription drugs 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 a Medicare Part B drug injection provided on July 16, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you had fallen out of your wheelchair and
needed assistance getting back up. A passerby called the ambulance however you say you did not need it. You
say that you were okay and did not need transportation to the hospital so you refused it. The Plan denied your
request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when
there is no transport.
The ambulance company did not provide transport services on September 11, 2019. The ambulance benefit is a
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee support sleeve provided by "the doctor" on September 24, 2019.You asked the Plan to pay forthe knee support sleeve (A4467). You say that you need the knee support sleeve.The Plan denied your request. The Plan says the knee support sleeve is not covered by Medicare or the Plan.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. Knee support sleeves are statutorily not covered by Medicare and the Evidence of Coverageclearly states that the Plan does not cover this item. Based on this information, we decided that Medicare rules for coverage of the knee support sleeve have not been met.Therefore, we decided that the Plan does not have to pay forthe knee support sleeve provided by "the doctor" on September 24,2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One (J7325).
You asked the Plan to pre-approve Synvisc-One. You say that the Synvisc-One is medically necessary. The Plan denied your request. The Plan says there is no documentation supporting the medical necessity for a step-therapy exception.
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 Synvisc-One. Our reviewer says that the member has not tried and failed a trial of Orthovisc and Monovisc. Our physician reviewer found the documentation does not support that Orthovisc and Monovisc would likely be less effective or have adverse effects. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Synvisc-One have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One (J7325).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
You asked the Plan to pre-approve Euflexxa. You say that this is medically necessary. The Plan denied your request. The Plan says that they did not receive documentation supporting the medical necessity for a step therapy exception.
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 Euflexxa. Our reviewer says that Euflexxa is not medically reasonable and necessary for the enrollee in this case. The documentation does not support that the enrollee has tried and failed Monovisc or that it would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. Our physician reviewer found that the enrollee's condition does not meet step therapy criteria for Euflexxa. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for the mammogram and ultrasound provided
on October 15, 2019.
You asked the Plan to waive the deductible for the mammogram and ultrasound. You say that these were
diagnostic. You say that you do not know why you have a charge. The Plan denied your request. The Plan says
the deductible applied correctly.
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 your in-network deductible is $300. This is the amount you have to pay out-ofpocket
before we will pay our share for your covered in-network medical services. Outpatient diagnostic test
are not excluded from the deductible.
The item or service you asked the Plan to waive the deductible for falls within the "Outpatient diagnostic tests
and therapeutic services and supplies" benefit category. The Plan has followed Medicare rules by clearly
disclosing in the contract that your $300 in-network deductible applies to outpatient diagnostic tests. This cost
sharing is a contractual obligation that had not been met at the time the mammogram and ultrasound was
received on October 15, 2019. Therefore, we decided that the Plan does not have to waive the deductible for
the mammogram and ultrasound provided on October 15, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on April 26, 2018.
You asked the Plan to pay for the ambulance services. You say that you were advised due to the plan
transitioning to a new address that your claims were not processes and you should not be held liable for errors
with mail or the claims department. The Plan denied your request. The Plan says the claim was received past
the timely filing limit.
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 May 21, 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 the ambulance services provided on April 26, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on September 18, 2019.
You asked the Plan to pay for the annual wellness visit. You say that you received a note stating that you were due for your Annual Wellness visit and you were about to leave the country an on extended trip. The Plan denied your request. The Plan says you previously received an Annual Wellness Visit exam on February 12, 2019.
The Plan must follow Medicare rules. Medicare rules say that that plans must pay for a medical service or item if regular Medicare would pay for it. The Plan offers an Annual Wellness Visit benefit, therefore the Plan's rules apply in this case. We looked at the file, contract and Medicare rules. Based on this information, we decided that Plan rules for coverage of the annual wellness visit have not been met. Specifically, the record indicates you received an Annual Wellness Visit exam on February 12, 2019. The Plan contract clearly states that an Annual Wellness Visit is covered once per 12 months. Therefore, we decided that the Plan does not have to pay for an annual wellness visit (G0439) provided on September 18, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for a CT Scan of the head or brain (70450) provided on
September 9, 2019.
You asked the Plan to pay for the CT Scan. You say that you would like reconsideration based on the records
submitted. The Plan denied your request. The Plan says the records attached with the member's appeal do not
contain any patient identifiers and therefore it could not be confirmed that the records received are for the
member.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment
for any item or service, the information submitted by the supplier or provider must corroborate the
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have
been met.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the CT Scan have not been met. Specifically, the medical records do not include the member's
name. The information submitted does not corroborate the documentation in the beneficiary's medical
documentation. Therefore, we decided that the Plan does not have to pay for a CT Scan of the head or brain
(70450) provided on September 9, 2019.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay fora one-month supply allowance for a therapeutic continuous glucose monitor provided on August 10, 2019.You asked the Plan to pay fora one-month supply allowance for a therapeutic continuous glucose monitor (K0553). You say that you are billing according to Medicare guidelines.The Plan denied your request. The Plan says that that the date of service does not match theshipping/billing invoice date.The Plan must follow Medicare rules. The rules state that a supplier does not have to deliver supplies used with a therapeutic CGM every month in order to bill code K0553 every month. In order to bill code K0553, the supplier must have previously delivered quantities of supplies that are sufficient to last for one (1) full month following the DOS on the claim. No more than 1 unit of service (UOS) for code K0553 per month is billable at a time. Regardless of utilization, a supplier must not dispense more than a three (3) -month quantity of BGM testingsupplies at a time.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a one-month supply allowance for therapeutic continuous glucose monitor have been met. Specifically, the supplies in this case were delivered in a 90-day supply for K0553, which the Proof of Delivery supports. The supplier is only billing one unit of K0553 at a time for supplies that are sufficient for one full month following the DOS on the claim. The supplier in this case is billing in accordance to Medicare rules for continuous glucose monitoring supplies. Therefore, we decided that the Plan has to pay fora one-month supply allowance for a therapeutic continuous glucose monitor provided on August 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from July 8, 2019 to August 8, 2019.You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received during the period in question 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 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 that 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 July 8, 2019 to August 8, 2019.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to reduce the copayment for the SNF stay. We decided that the Plan does not have to waive the copayment for the SNF stay.
You asked the Plan to reduce the copayment for the SNF stay. You say that you were at a rehabilitation center. You say that your copayment should be $300. The Plan says that the copayment applied correctly.
We decided that the Plan has to reduce the copayment for the SNF stay.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The day before you are discharged from an inpatient facility is considered your last inpatient day.
The plan says that you must pay $680 for a 16 day SNF stay. The copayment does not apply to the day you are discharged. Therefore, we decided that the Plan has to reduce the copayment for the SNF stay from $680 to $620.
We also decided that the Plan does not have to waive the copayment for the SNF stay.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles, and coinsurance). The records show that the provider is a skilled nursing facility. Your contract with the Plan clearly says that for each admission, you must pay $20 per day for days 1-20 of a benefit period and $60 per day for days 21-44.
Therefore, we decided that the Plan does not have to waive the copayment for the SNF stay.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from September 8, 2019 to September 9, 2019.
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that the plan should be
responsible for the charges. The Plan denied your request. The Plan says the claims were processed correctly
and you are being charged the correct amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that Southern California
Region members must pay a $285 copayment per day for days 1-7 for inpatient hospital care.
You have been asked to pay a $285 copayment for an inpatient hospital stay. An inpatient hospital stay falls
within the inpatient hospital 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
an inpatient hospital stay