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

We decided that the Plan does not have to pre-approveuse of Naglazyme.You asked the Plan to pre-approveNaglazyme. 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 off-label use of Naglazyme for the enrollee's condition is not medically accepted.The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Naglazyme. Our reviewer says that the enrollee does not meet the Medicare criteria for use of Naglazyme. Our physician reviewer found the requested drug Naglazyme has not been approved by the Food and Drug Administration (FDA) for use in the enrollee's condition, nor is its use supported by Medicare. There is not any published literature available showing that Naglazyme is safeand effective for use in the enrollee's condition, therefore it cannot be concluded that it is safe and effective 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 Naglazyme have not been met.Therefore, we decided that the Plan does not have to pre-approveuse of Naglazyme.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 2, 2019 to September 20, 2019.
You asked the Plan to pay for the glucose monitor (E2100), test strips (A4253), lancets (A4259), control solution (A4256), and lancet device (A4258). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered. Therefore, we decided that the Plan does not have to pay for the glucose monitor, test strips, lancets, control solution, and lancet device provided from July 2, 2019 to September 20, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 14, 2019 by out of network provider.You asked the Plan to pay for physician services. You say that you would like these services approved for payment.The Plan denied your request. The Plan says there are in-network providers available for these 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 forthe medical services provided on August 14, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe office visit provided on August 8, 2019.You asked the Plan to waive the copayment forthe office visit. You say that you do not plan on paying because another surgery has to be scheduled.The Plan denied your request. The Plan says the copayment 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 $40 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant. You have been asked to pay a $40 copayment for the office visit. The office 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 decidedthat the Plan does not have to waive the copayment forthe office visit provided on August 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Enbrel SureClick injector pens.You asked the Plan to pre-approveself-administered drugs. You say that you are appealing based on medical necessity.The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits. The Plan also says that the enrollee's Medicare Part D prescription drug benefits may be administered.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-approveEnbrel SureClick injector pens.Benefits for self-administered drugsmay be available under Medicare Part D.Contactthe 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 the medical services provided on August 26, 2019 by out of network provider

You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says services rendered by nonparticipating providers require prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan 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 August 26, 2019 by out of network provider
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on June 25, 2019 by an out of network provider.  You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the referring provider is out-of-network. The Plan says that the member has no out-of-network benefits.
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 June 25, 2019 by the out of network provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0652).You asked the Plan to preapprove a pneumatic compression device. You say that the enrollee requires the device.The Plan denied your request. The Plan says the documentation did not support the 4-week trial using the basic pump that Medicare requires.The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided.Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0652)
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided from August 11, 2019 to October 30, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided from August 11, 2019 to October 30, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forarthroplasty provided by "the provider", on April 13, 2017.You asked the Plan to waive the coinsurance forarthroplasty. You say that you disagree with the reprocessing of the claim.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 30% coinsurance for outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers. You received arthroplasty on April 13, 2017. Arthroplasty is considered an outpatient surgical procedure. Therefore, you are responsible to pay $6,267.60, which is less than the 30% coinsurance amount. You have been asked to pay the total coinsurance amount of $6,267.60 for arthroplasty. Arthroplasty 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 coinsurance forarthroplasty provided by "the provider" on April 13, 2017.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient clinic visit provided by on August 15, 2019.You asked the Plan to waive the copayment forthe outpatient clinic visit. You say that you were informed there would be a $50 copayment. You say that you were not informed there would be a fee for the facility.ThePlan denied your request. The Plan says the copayment 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 thePlan clearly says that you must pay a $300 copayment for each Medicare-covered outpatient hospital facility visit.You have been asked to pay $108.43, which is less than the standard $300 copayment for the outpatient clinic visit. The outpatient clinic visit falls within the "Outpatient hospital 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 forthe outpatient clinic visit provided by on August 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the office visit and pessary provided on August 8, 2019.
You asked the Plan to waive the cost share for the office visit and pessary. You submitted your bill for review. You say that the bill should be reprocessed. The Plan denied your request. The Plan says the cost share 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 $50 copayment for services obtained from a specialist and 20% coinsurance for each Medicare-covered prosthetic or orthotic device. You have been asked to pay a total of $52.99 for the office visit and pessary.
Service

Office Visit
Allowed Amount - $87.54
Standard Cost Share - $50
Member Liability - $50

Pessary
Allowed Amount - $14.93
Standard Cost Share - 20%
Member Liability - $2.99

TOTAL:
$52.99

The office visit falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The pessary falls within the "Prosthetic Devices 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 cost share for the office visit and pessary provided on August 8, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided from August 12, 2019 to October 31, 2019.You asked the Plan to pay fortest strips (A4253), lancets (A4259), control solution (A4256), and batteries (A4235). You say that the Plan should pay this claim.The Plan denied your request. The Plan says the Delivery Ticket did not include the carriers tracking number and the Proof of Delivery did not include details to corroborate the Delivery Ticket.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The Delivery Ticket does not have the tracking number on it and the Proof of Delivery does not have a description of the items delivered.Therefore, we decided that the Plan does not have to pay fortest strips, lancets, control solution, and batteries provided from August 12, 2019 to October 31, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share forthe arthrocentesis, x-ray and hyaluronan injections provided on July 25, 2019, August 9, 2019 and August 16, 2019.You asked the Plan to waive the cost share forthe arthrocentesis, x-ray and hyaluronan injections. You say that you were not informed of additional payments required outside of the $45 copayment. You say that you were informed prior to treatments that they were approved and would be covered by insurance.The Plan denied your request. The Plan says the cost share 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 $45 copayment for services obtained from aspecialist, an $8 copayment for each Medicare-covered standard x-ray serviceand 20% coinsurance for each Medicare-covered Part B drug.
You have been asked to pay a total of $714.12 for the arthrocentesis, x-ray and hyaluronan injections.
You have been asked to pay a total of $714.12 for the arthrocentesis, x-ray and hyaluronan injections. Date of ServiceServiceAllowed AmountStandard CostMember LiabilityJuly 25, 2019Arthrocentesis54.06$45$45July 25, 2019X-Ray$90.41$8$8July 25, 2019Hyaluronan Injections$1,075.2020%$215.04August 9, 2019Arthrocentesis$81.09$45$0August 9, 2019X-Ray$90.41$8$8August 9, 2019Hyaluronan Injections$1,075.2020%$215.04August 16, 2019Arthrocentesis$81.09$45$0August 16, 2019X-Ray$90.41$8$8August 16, 2019Hyaluronan Injections$1,075.2020%$215.04TOTAL:$714.12The arthrocentesis falls within the "Physician/Practitioner Services, Including Doctor's Office Visits" benefit category. The x-ray falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies: benefit category. The hyaluronan injections fall 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 cost share forthe arthrocentesis, x-ray and hyaluronan injections provided on July 25, 2019, August 9, 2019 and August 16, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 12, 2019 to July 10, 2019 by out of network provider.You asked the Plan to pay forhome health services. You say that due to network provider closing, another provider has taken over full care of those patients. You say that you would like this denied claim reconsidered for payment.The Plan denied your request. ThePlan says no prior authorization was obtained for these 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 forthe medical services provided on June 12, 2019 to July 10, 2019 by out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shoulder arthroscopy services provided to "the beneficiary" on June 21, 2019.You asked the Plan to pay forthe services provided. The Plan denied your request. The Plan says the procedure codes were not substantiated by the clinical 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.The CPT Code Manual definition of code 29827 is Arthroscopy, shoulder, surgical; with rotator cuff repair. The CPT Code Manual definition of code 29826 is Arthroscopy, shoulder, surgical; decompression ofsubacromial space with partial acromioplasty, with coracoacromial ligament (ie, arch) release, when performed (List separately in addition to code for primary procedure).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 services provided. Our reviewer found that the medical records provided do not document code 29826being performed on June 21, 2019, therefore the service cannot be verified. An add-on code is only eligible for reimbursement consideration if the primary procedure code for the procedure can be validated and is reimbursed. CPT code 29827 -Arthroscopy, shoulder, surgical; with rotator cuff repair could not be validated by the submitted medical records either. This description was not found in the operative report.We looked at this review, the file, and Medicare rules. Based on theinformationprovided, we decided that Medicare rules for coverage of the services provided have not been met.Therefore, we decided that the Plan does not have to pay forthe shoulder arthroscopy services provided to "the beneficiary" on June 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a complete upper denture (D5110).You asked the Plan to pre-approvethe dental item. The Plan denied your request. The Plan says the frequency limit for the complete denture has been reached.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 and a complete denture is listed a covered item, the frequency limit of 1 every 5 years has been reached. The Record shows that you last received a complete denture on March 30, 2018.Therefore, we decided that the Plan does not have to pre-approvea complete upper denture (D5110).