Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Botox injections rendered on February 5, 2020.
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 are cosmetic and not covered.
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures are not covered. We looked at the file and Medicare rules. The file shows that the Botox injections were given at the suprabrow, procerus, and corrugator muscles. These locations are not consistent with the treatment of blepharospasm and are considered cosmetic in nature. 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 pay for the Botox injections rendered on February 5, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment forthe ultrasound of the chest provided on January 8, 2020.You asked the Plan to waive the copayment forthe ultrasound. You say that you already had to pay for an ultrasound for the same reason. You say you should not pay for another ultrasound again since your doctor insisted you get another one. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a$100 copayment for ultrasounds. You have been asked to pay a $100 copayment for the ultrasound. The ultrasound falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment forthe ultrasound of thechest provided on January 8, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital services (99223, 99232 and 99239) provided on January 3, 2019 through January 7, 2019.You asked the Plan to pay forhospital services (99223, 99232 and 99239) provided on January 3, 2019 through January 7, 2019.You say that you would like reconsideration because the member did not present with the correct insurance information.The Plan denied your request. The Plan says payment is not allowed for this claim because it was submitted after timely filing limitations and proof of timely filing was not received.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 hospital services was not filed until February 7, 2020. 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
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay foran annual physical (99387) provided on December 26, 2019.You asked the Plan to pay forthe annual physical. You say that you would like reconsideration because you were not informed that this service would not be covered.The Plan denied your request. The Plan says this is not a covered benefit because this service has been previously rendered on January 18, 2019.The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the annual physical have not been met. Specifically, the record indicates that you received an annual physical on January 18, 2019. The annual physical rendered on December 26, 2019 is not a covered benefit because it was received within the same calendar year as the initial physical.Therefore, we decided that the Plan does not have to pay foran annual physical (99387) provided on December 26, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the mammogram provided on January 6,
2020.
You asked the Plan to waive the copayment for the mammogram. You say that this was an annual mammogram
that was required due to male breast cancer where a full mastectomy was required on the left side. The Plan
denied your request. The Plan says you have been charged the correct cost sharing amount.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $130
copayment for outpatient x-rays taken at any other location.
You have been asked to pay a $130 copayment for the mammogram. The mammogram falls within the
"Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows a history
of breast cancer which makes the mammogram diagnostic in nature.
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that
the Plan does not have to waive the copayment for the mammogram provided on January 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on February 10, 2020. You asked the Plan to pay for lab tests. You say that your lab performed the tests ordered by the referring physician. The Plan denied your request. The Plan says the denial of payment for these services is correct, because Medicare does not cover screening services with no relation to a medical diagnosis of disease for the health of the enrollee. 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 rules say that a physician order or clear intent to order specific lab services is required for covered lab services. The documentation submitted does not include a valid physician order or clear intent to order the specific lab services billed on this claim to show that the tests were ordered for non-screening purposes. Based on this information, we decided that the Medicare criteria for payment of lab tests has not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on February 10, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on February 4, 2020 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says they do not deny that these services are medically necessary. The Plan says that these services could have been provided in-network.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 an office visit provided on February 4, 2020 by an out of network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory testing provided on November 25, 2019.
You asked the Plan to pay for lab tests. You say that the ordering physician's medical record is kept by the
physician and never supplied to you. The Plan denied your request. The Plan says that the denial of payment
for these services is correct, because the ordering provider did not submit medical records to determine the
clinical utility of testing.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or
payment. Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a
contract provider are considered approved by the plan unless notice is provided that the services will not be
covered.
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their
decision to deny your request. The Plan did not specify whether the ordering physician is in-network or out-of-network
with the Plan. The documentation submitted does not include prior notice from the Plan that these
services would not be covered. Without this information, we cannot determine whether the lab order made
constitutes plan-directed care. Therefore, the Plan has not shown that its decision to deny payment is correct or
justified by Medicare rules. Therefore, we decided that the Plan has to pay for laboratory testing provided on
November 25, 2019. If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve CT scan of abdomen and pelvis for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary for the enrollee's lung cancer diagnosis. The Plan denied your request. The Plan says there are no current signs or symptoms.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is not medically reasonable or necessary. Our physician reviewer found per the NCCN guidelines, this scan is not authorized for surveillance purposes. 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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve CT scan of abdomen and pelvis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for specialist services provided on January 21, 2020 by an out of network (OON) provider. 
 
You asked the Plan to pay for specialist services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for specialist services provided on January 21, 2020 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Humalog Kwikpen.
You asked the Plan to pre-approve the pen. You say that this is medically necessary. The Plan denied your
request. The Plan says Medicare says Part B programs can only provide limited benefits for prescription drugs.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Humalog Kwikpen.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit provided on February 11,
2020.
You asked the Plan to waive the copayment for the office visit. You say that the visit was a continuation of an
incomplete procedure. You say that you were informed there would be no charge. 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 each office visit to a specialist.
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. The records show that the
office visit was due to a diagnosis of iron deficiency. This means that you have been asked to pay the correct
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for
the office visit provided on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.
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 LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not support that you require services at the LTACH that are
not available at the acute care hospital where you are currently receiving care. There are no required medical
services identified that are available at the LTACH, that are not available at the current health care setting
being offered by the health plan. Consequently, the requested LTACH services are not medically necessary,
reasonable, and appropriate for your diagnosis and condition at this time.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on January 7, 2020 by an out
of network (OON) provider.
You asked the Plan to pay for office visit. You say that the enrollee gave incorrect insurance information at the
time of service. The Plan denied your request. The Plan says the denial of payment for this service is correct,
because this provider is out-of-network with the Plan and the referring provider is also out-of-network with the
Plan.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for the medical services provided on January 7, 2020
by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an external ambulatory insulin infusion pump and supplies. You asked the Plan to pre-approve an external ambulatory insulin infusion pump and supplies. You say that the enrollee cannot afford the insulin pump supplies. The Plan denied your request. The Plan says the enrollee is not testing four or more times a day or adjusting medications based on the results. 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. The lab results are from 2011, not current. Based on this information, we decided that Medicare rules for coverage of an external ambulatory insulin infusion pump and supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve an external ambulatory insulin infusion pump and supplies.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fora Medicare Part B drug provided on February 11, 2020.You asked the Plan to waive the coinsurance fora Medicare Part B drug. You say that you disagree with the charges because you have only been charged a $15 copayment in the past.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 20% coinsurance for Medicare Part B prescription drugs. You received a Medicare Part B drug on February 11, 2020. The allowed amount is $1,490.76 and 20% of that is $298.15. You have been asked to pay the total coinsurance amount of $298.15 for a Medicare Part B drug. A Medicare Part B drug 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 fora Medicare Part B drug provided on February 11, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee needs daily physician visits, labs, complex wound care, and hyperbaric treatments. The Plan denied your request. The Plan says the enrollee is not stable for discharge without a vascular exam being completed.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our physician reviewer found that the enrollee is currently undergoing treatment at an acute care hospital (ACH) for foot wounds and bacteremia. The enrollee is receiving wound care and a prolonged course of antibiotics. The enrollee is not intubated/ventilated. There is no evidence that the enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long-term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a lumbar (L2-L5) laminectomy surgery.You asked the Plan to pre-approve the spinal surgery. You say that the enrollee has been dealing with severe back pain for years and is not helped by any prior conservative treatment options. This surgery is needed.The Plan denied your request. The Plan says that there is not sufficient documentation that conservative care cannot treat the enrollee's pain. The need for surgery is not established.The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review thecase file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the spinal surgery. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 66-year-old woman with a diagnosis of Intervertebral disc stenosis of neural canal of lumbar region. The enrollee is on multiple medications, including pain medication. Multiple medication allergies are documented. A physical therapy ortho evaluation dated 5/28/20 documents that the enrollee has 10/10 pain all the time. The enrollee reported frequent falls, and that she couldn't control her bowel or bladder, and was unable to walk or stand for any length of time.She had weakness in her bilateral quadriceps, hamstrings, hip flexors, abductors, and adductors. It was noted that the enrollee was "currently unable to participate in skilled PT due to pain issues." The case file contains a Neurosurgery consult note dated 6/6/20. The enrollee reported intermittent leg weakness and intermittent loss of bowel and bladder function which was unchanged from previous hospitalizations. An MRI on 5/29/20 demonstrated multilevel degenerative change in the lumbar spine with moderate to severe spinal canal stenosis. The enrollee in this case has severe spinal canal stenosis, and the documentation supports that she has not responded to conservative treatment. As such, the requested surgical intervention is supported.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 spinal surgery have been met.Therefore, we decided that the Plan has to pre-approve a lumbar (L2-L5) laminectomy surgery. If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.