Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued acute inpatient rehabilitation facility (IRF) services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says that the enrollee can have the care needed at an alternate level, such as like skilled nursing.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the member's condition differently compared with therapy provided at a less intense level. The member's care can be appropriately provided at an SNF level. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve continued acute inpatient rehabilitation facility (IRF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora TDAP vaccine and administration (90715 and 90471) provided on December 4, 2019.You asked the Plan to pay for the TDAP vaccine. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says your request is not covered under Medicare Part B.In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine.Therefore, we decided that the Plan does not have to pay fora TDAP vaccine and administration (90715 and 90471) provided on December 4, 2019.Benefits for the TDAP vaccine may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.Your complaint about receiving incorrect information from the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for an inpatient hospital stay and Computed Tomography (CT) of the Abdomen and Pelvis (74177) provided July 24 to August 14, 2019.You asked the Plan to waive the copayments for the inpatient stay and CT scan. You say that the copayments should be waived.The Plan denied your request. The Plan says the correct cost share was applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $695 copayment per admission for inpatient stays and a $180 copayment for Diagnostic Imaging. You have been asked to pay a $695 copayment per admission for inpatient stays and a $180 copayment for Diagnostic Imaging. 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 copayments for an inpatient hospital stay and Computed Tomography (CT) of the Abdomen and Pelvis (74177) provided July 24 to August 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chiropractic services provided to the enrollee from October 7, 2019 to October 18, 2019.
You asked the Plan to pay for chiropractic services. You say that these services should be covered by the Plan. The Plan denied your request. The Plan says while a portion of this claim was paid, only those services that directly relate to manual manipulation of the spine to correct subluxation are covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that services coded as 97012, 97014 and 97530 are not covered by Medicare. Therefore, we decided that the Plan does not have to pay for a portion of the chiropractic services provided to the enrollee from October 7, 2019 to October 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Herceptin.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says services related to a clinical trial are covered by Original Medicare.
The Plan must follow Medicare rules. The rules say that Medicare pays for the routine costs of qualifying clinical trials. We looked at the file and Medicare rules. The Herceptin is being requested for use in a clinical trial. The Plan cannot approve these services, as they are covered by Original Medicare. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Herceptin.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient mental health services you received from May 24, 2019 to December 11, 2019.
You asked the Plan to pay for the services provided. You say that you are not covered under any other health plan. The Plan denied your request. The Plan says a primary explanation of benefits is needed.
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 records show that you had a different primary provider until December 31, 2019. The Plan has met its obligation with regards to coordination of benefits. As the secondary insurer, the Plan cannot be held responsible for the services provided until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for the outpatient mental health services you received from May 24, 2019 to December 11, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on October 8, 2019 by an out of network (OON) provider.You asked the Plan to pay for the OON services. You say that care was given to the enrollee in good faith.The Plan denied your request. The Plan says prior authorization is required, but was not 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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services.Therefore, we decided that the Plan does not have to pay for the medical services provided on October 8, 2019 by an out of network (OON) provider.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lucentis (J2778).You asked the Plan to pre-approve Lucentis. You say that the medication is necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for a step therapy exception has not been met.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 Lucentis. Our reviewer says that the medication is not medically necessary. Our physician reviewer found the provided medical records do not indicate that the Plan's required drug would likely be less effective and/or likely have adverse effects for the enrollee.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Lucentis have not been met.Therefore, we decided that the Plan does not have to pre-approve Lucentis (J2778).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for syringes coded A4657 provided from July 1, 2019 to July 31, 2019.
You asked the Plan to pay for syringes. 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 separately payable.
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 code A4657 is syringe, with or without needle, each. We find that CPT code A4657 is not supported in the medical record. Specifically, the syringes were also billed with dialysis services. Therefore, these supplies are included in the payment for the dialysis services. Based on this information, we decided that Medicare rules for coverage of syringes have not been met. Therefore, we decided that the Plan does not have to pay for syringes coded A4657 provided from July 1, 2019 to July 31, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on December 14, 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. The Plan confirmed that you are not being billed for these services.Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) provided on December 14, 2019 by an out of network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to issue reimbursement for the home health aide services (S9122) provided October 3, 2019 to December 20, 2019.You asked the Plan to issue reimbursement for these services. You say that you are requesting a reconsideration of the Plan's denial for payment.The Plan denied your request. The Plan says the services were provided by an out of network provider, who is not certified by Medicare.The Plan must follow Medicare rules. The rules say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.The services at issue in this appeal were provided by an out of network provider, who is not certified by Medicare. Based on this information, we have decided that Medicare rules for coverage of these services have not been met. Therefore,we decided that the Plan does not have to issue reimbursement for the home health aide services (S9122) provided October3, 2019 to December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on April 29, 2019.
You asked the Plan to pay for the critical care services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not support a critical care visit of 30-74 minutes was performed on the billed date of service.
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 code 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the record. Specifically, the record indicates that 25 minutes was spent in critical care. Critical care services of less than 30 minutes is not reported separately using the critical care codes. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on April 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the diagnostic colonoscopy you received on September 6, 2019.
You asked the Plan to waive the copay for the colonoscopy. You say that you did not have polyps removed on the date of service at issue. The Plan denied your request. The Plan says the copays were applied correctly based on the plan benefits.
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 $300 copay for each outpatient surgery.
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 waive the copay for the colonoscopy. Our reviewer says that the medical records indicate the colonoscopy was performed. However, due to poor bowel prep, you returned to have a repeat procedure. During the procedure at issue, polyps were removed. Both colonoscopies are valid and billable. Therefore, the both claims were processed appropriately. You have been asked to pay a $300 copay for the colonoscopy. The colonoscopy falls within the outpatient surgery 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 copay for the diagnostic colonoscopy you received on September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the specialist services rendered on March 22, 2019.
You asked the Plan to waive the coinsurance for these services. You say that the coinsurance is a financial hardship. 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 for each covered specialist office visit.
Review of the file shows that you received specialist services on March 22, 2019. You have been asked to pay a 20% coinsurance for these services, for a total of $39.29. These services fall within the covered specialist office visit 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 the specialist services rendered on March 22, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve incontinence supplies.
You asked the Plan to pre-approve incontinence supplies. You say that the requested supplies should be covered for the enrollee. 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 incontinence supplies are not covered because they are hygienic items that are non-reusable. While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the mammography services (77063, 77067) provided on
January 30, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the mammography services. You say that the services were medically necessary.
The Plan denied your request. The Plan says the services were not emergent or preauthorized. There were
network providers available.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the services at issue in this appeal. 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 the mammography services (77063, 77067) provided on January 30, 2019 by an
out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Xeljanz.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Xeljanz.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for assisted living services provided on November 1, 2019 by an out of network (OON) provider.You asked the Plan to pay for assisted living services. You say that these services were provided in an assisted living facility. You say that you would like this appeal reprocessed and approved for payment.The Plan denied your request. The Plan says there is no claim on file for the facility. The Plan says that 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 assisted living services provided on November 1, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulatory infusion pump and supplies provided from September 10, 2019 to September 12, 2019.You asked the Plan to pay for the ambulatory infusion pump (E0781) and supplies (A4222). You say that the pump and supplies were medically necessary.The Plan denied your request. The Plan says the enrollee's medical issue is not a covered diagnosis for an external infusion pump and the drug is not on the list of approved medication that are suitable for administration by way of an external infusion pump. 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 ambulatory infusion pump (E0781) and supplies (A4222). Our reviewer says that the provided items were not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee had a diagnosis of osteomyelitis of the mandible. The enrollee completed 6 weeks of IV antibiotics (initially Ertapenem, and then Unasyn). The enrollee had a condition for which parenteral administration of the drug in the home was reasonable and necessary. However, an infusion pump was not necessary to safely administer the drug. There is no documentation that systemic toxicity or adverse effects of the drug were unavoidable without infusing it at a strictly controlled rate as indicated in the Physicians Desk Reference, or the U.S. Pharmacopeia Drug Information.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 ambulatory infusion pump (E0781) and supplies (A4222) have not been met.Therefore, we decided that the Plan does not have to pay for the ambulatory infusion pump and supplies provided from September 10, 2019 to September 12, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Norco.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not a covered 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-approve Norco.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.