Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approveadditional routine transportation trips.You asked the Plan to pre-approveadditional routine transportation trips. You say that you have ongoing appointments you need transportation to.The Plan denied your request. The Plan says that you have exhausted this benefit.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 twenty-four (24) 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-approveadditional routine transportation trips.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forthe computed tomography (CT) scan of the soft tissue of the neck rendered.You asked the Plan to waive the coinsurance forthese services. You say that you have not had a copayment in the past.The Plan denied your request. The Plan says the coinsurance was applied correctly.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance, up to a maximum of $75 per day, for Medicare-covered diagnostic radiology services. Review of the file shows that you received a CT scan . You have been asked to pay a 20% coinsurance for these services, for a total of $43.31. These services fall within the Medicare-covered diagnostic radiology services 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 computed tomography (CT) scan of the soft tissue of the neck rendered .
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approveSNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that you can continue to receive appropriate intensive rehabilitation services at the IRF.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for SNF services.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran EGD provided.You asked the Plan to waive the copayment foran EGD. You say that you were told that you would not owe a copayment and disagree with 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 you must pay a$325 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers. You have been asked to pay a $325 copayment for an EGD. An EGD falls within the outpatient surgery and other medical 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 youagreed to pay when you enrolled in the Plan.Therefore, we decided that the Plan does not have to waive the copayment foran EGD provided .
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora specialist visit provided .You asked the Plan to waive the copayment fora specialist visit. You say that you feel that the doctor did nothing and never gave you the results of the allergy testing.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 $50 copayment for specialist visits.The medical records show that you had a specialist visit . Therefore, you are responsible to pay the $50 copayment.  You have been asked to pay a $50 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including 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 nothave to waive the copayment fora specialist visit provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea power wheelchair.You asked the Planto pre-approvethe wheelchair. You say that this is medically necessary.The Plandenied your request. The Plansaysa cane or walker for short distances and a manual wheelchair for longer distances would be more appropriate.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 the wheelchair. Our reviewer says that the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the health assessment dated 9/16/20 indicates that you can walk for short distances in the home with a cane or walker. You are independent in eating, dressing, transferring, and toileting. You are noted to have 5/5 strength in the upper extremities per a 2/17/21 progress note, therefore the documentation does not indicate you lack the upper body strength to use a walker or manual wheelchair.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 wheelchair have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea power wheelchair.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveLibrax capsules.You asked the Plan to pre-approveLibrax capsules. You say that you would like the Plan to reconsider their denial.The Plan denied your request. The Plan says Librax capsules are not covered under the enrollee's Medicare Part B benefit.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-approveLibrax capsules.Benefits for Librax capsulesmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefitsand appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe assessment for prescriptive eye wear using a range of lens powers (92015) and laser repair to improve eye fluid flow (65855) provided .You asked the Plan to pay forthe assessment for prescriptive eye wear and laser eye repair. You say that you were not aware the services would be needed to request prior authorization.The Plan denied your request. The Plan says the services were done without prior authorization and do not meet criteria for OON coverage.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 they are rendered by a network provider.
We looked at the file and the Plan's rules. The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 Based on this information, we decided that the Plan's rules for coverage of the assessment for prescriptive eye wear and laser eye repair have not been met.Therefore, we decided that the Plan does not have to pay forthe assessment for prescriptive eye wear using a range of lens powers (92015) and laser repair to improve eye fluid flow (65855) provided.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea Freestyle Libre continuous glucose monitor (CGM).You asked the Plan to pre-approvea Freestyle Libre CGM. You say that this would be helpful to the enrollee.The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverageThe Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and require frequent self-adjustment of insulin dosage based on the blood glucose testing results.We looked at thefile and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day or use insulin with at least three daily injections. 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-approvea Freestyle Libre continuous glucose monitor (CGM).
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay foran emergency room visit (99285) provided .You asked the Plan to pay foran emergency room visit. You say that this should be covered.The Plan denied your request.The Plan says this must be billed to the enrollee's primary insurance.The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to bill the enrollee's primary insurance. As the secondary insurer, the Plan cannot be held responsible for an emergency room visit until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay foran emergency room visit (99285) provided.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services provided.You asked the Plan to pay forthe ambulance services. You say that you did not receive transport because you are a Covid-19 survivor along with health related problems.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. 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 forthe ambulance services provided .
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 62370) provided .You asked the Plan to pay forthe services. The Plan denied your request. The Plan says the services were billed with an inappropriate modifier.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 62370-LT is not supported in the medical record. Specifically, the requested code does not have a laterality. It is inappropriate to bill modifiers LT/RT for procedures that do not have a laterality. 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 forthe services (CPT 62370) provided .
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOpdivo.You asked the Plan to pre-approveOpdivo. You say that the services are necessary.The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.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 Opdivo. Our reviewer says that the medication is not medically necessary. Our physician reviewer found Nivolumab (Opdivo) isnot FDA approved for treatment of gastroesophageal cancer. Use is not supported by major drug compendia and combination therapy with FOLFOX and trastuzumab is not supported by phase III trials in the medical literature. The service is not reasonable or medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met.Therefore, we decided that the Plan does not have to pre-approveOpdivo.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forinitial nursing facility care providedon .You asked the Plan to pay forthe initial 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 topay 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 Plandid 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 forinitial nursing facility care provided .
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approveSNF services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the continuation of skilled services can be provided on an intermittent basis on an outpatient basis, in a long-term care facility, or at the home with home health care services.The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF services.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 services have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approveHyperbaric Oxygen Therapy.You asked the Plan to pre-approvethe Hyperbaric Oxygen Therapy. You say that you would like reconsideration because this is the best option for you to keep your limb.The Plan denied your request. The Plan says your condition is not a covered indication.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 Hyperbaric Oxygen Therapy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Medicare rules say that Hyberbaric Oxygen Therapy treatment is not covered for the treatment of chronic peripheral vascular diseaseWe looked at this physician's review, the file, and Medicare rules. Based on this information, we decided thatMedicare rules for coverage of the Hyperbaric Oxygen Therapy have not been met.Therefore, we decided that the Plan does not have to pre-approveHyperbaric Oxygen Therapy
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran eye examination and refraction provided by an out of network (OON) provider.You asked the Plan to pay foreye exam. You say that you believe your policy covers one eye exam per year.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.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 had network providers available who could have provided 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 foran eye examination and refraction provided by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forinfectious agent screening (87798) provided .You asked the Plan to pay forinfectious agent screening. You say that this should be covered.The Plan denied your request. The Plan says this was performed for screening purposes.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The test at issue in this appeal, infectious agent screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes.Therefore, we decided that the Plan does not have to pay forinfectious agent screening (87798) provided.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forambulance services provided.You asked the Plan to waive the copayment forambulance services. You say that you did not request the service and disagree with 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 you must pay a $250 copayment for ambulance services. You have been asked to pay a $250 copayment for ambulance services. Ambulance services fall within the ambulance services 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 forambulance services provided .
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe reflectance confocal microscopy provided.You asked the Plan to pay forthe microscopy. The Plan denied your request. The Plan says this is not medically necessary.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 microscopy. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found Mohs surgery is the standard of care for this type of melanoma lesions.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 microscopy have not been met.Therefore, we decided that the Plan does not have to pay forthe reflectance confocal microscopy provided .
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee .You asked the Plan to pay forhome health services. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not payable.The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the billed dates of service do not match the number of units billed.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee