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

We decided that the Plan does not have to pay forthe hemoglobin testing provided to the enrollee on November 4, 2019.You asked the Plan to pay forthe testing. The Plan denied your request. The Plan says screening tests are not covered.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, the hemoglobin testing, 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 forthe hemoglobin testing provided to the enrollee on November 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve weekly Procrit injections to be provided while out of area (OOA).You asked the Plan to pre-approve the OOA Procrit injections. You say that the enrollee will be leaving the service area and requires continued weekly injections to maintain adequate hemoglobin levels.The Plan denied your request. The Plan says this is not an urgently needed OOA service since the need is known prior to leaving the service area.Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care.  In this case, the requested services do not meet the definition of urgently needed out of area care.Therefore, we decided that the Plan does not have to pre-approve weekly Procrit injections to be provided while out of area (OOA).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the coinsurance for the genital surgery provided on October 11, 2019.
You asked the Plan to reduce the coinsurance for the genital surgery. You say that you were told this service would be covered at the in-network rate. 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 30% coinsurance for surgery services at an out-of-network outpatient hospital. You have been asked to pay $704.34 which is less than the standard amount for the genital surgery. The genital surgery falls within the "Outpatient hospital services" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
October 11, 2019
Genital surgery
$2,935.64
30%
$704.34 - You have met your maximum out-of-pocket amount with this service
Total
$704.34
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 reduce the coinsurance for the genital surgery provided on October 11, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.You asked the Plan to pre-approve the allowance for healthy food purchases and/or electricity, water and/or phone bill payments. You say that you have high blood pressure and you are under the care of a cardiologist. You say that you have osteoarthritis and fibromyalgia and you are being treated for these conditions by a rheumatologist. You say that your physicians can verify this information. The Plan denied your request. The Plan says you do not have an eligible chronic medical condition for the allowance.The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning.In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and the Plan's rules. The file shows that the medical conditions you have stated are not eligible medical conditions under the Plan's benefit.Therefore, we decided that the Plan does not have to pre-approve an allowance for healthy food purchases and/or electricity, water and/or phone bill payments.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approve IRF care. You say that the clinical documentation provided supports the need for IRF care.The Plan denied your request. The Plan says the guidelines for coverage have not been met.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 correctin 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. Our physician reviewer found the enrollee's medical conditions appear stable and there are no wound care needs. There are no unaddressed medical issues and the enrollee does not require medical oversight of her condition in an acute hospital level of care. The enrollee requires physical therapy for mobility and occupational therapy for remaining activities of daily living and adaptive equipment. Occupational therapy is also indicated for treating the enrollee's right shoulder pain and for decreasing the chances of secondary complications such as CRPS or adhesive capsulitis. The enrollee is unable to perform essential activities of daily living without assistance of more than 1 person and requires an intensive rehabilitation therapy program. The enrollee is limited by pain after her recent fall as well as her comorbid medical conditions. The enrollee is also at significant risk for repeat fall related injuries and would not be expected to be able to safely fully participate in or benefit from the required intensity of an acute rehabilitation therapy program. There is no reason to think that an intensive rehabilitation therapy program would significantly impact the enrollee's condition differently compared with therapy provided at a less intense level. The enrollee's care can be appropriately provided at an skilled nursing facility (SNF) level.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the crown provided on November 20, 2019.
You asked the Plan to pay for the crown. You say that you believe this payment is extremely high and should
be covered by your plan. The Plan denied your request. The Plan says this service is not a covered benefit.
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, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown
provided on November 20, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve complete lower denture (D5120).You asked the Plan to pre-approvethe denture. You say that the current dentures were made too big and even after taking them back twice for adjustments she still cannot wear them because of the bone loss on the bottom of her mouthThe Plan denied your request. The Plan says this request exceeds the benefit limitation.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. Dentures are approved for coverage once every 5 years. Records show that you received the complete lower dentures (D5120) on July 2, 2019, therefore this benefit is exhausted. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approvecomplete lower denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on May 1, 2019 by an out of network (OON) provider.You asked the Plan to pay for the wrist excision (25111). You say that you would like reconsideration as these services did not require authorization and were medically necessary. The Plan denied your request. The Plan says the services provided require prior authorization and no 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 the medical services provided on May 1, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pay for the continuous glucose monitor supply allowance provided by Quest Health Solutions on September 3, 2019.You asked the Plan to pay for the supply allowance (K0553). You say that the supplies were medically necessary.The Plan denied your request. The Plan says that the medical records and Delivery Ticket appear to have been altered.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 contains a valid physician order and proof of delivery for the supplies provided in this case.Therefore, we decided that the Plan has to pay for the continuous glucose monitor supply allowance provided by Quest Health Solutions on September 3, 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay forthe ambulance services.You asked the Plan to pay forthe ambulance services. You say that the enrollee refused medical transportation however they were assessed by the EMS services and had their vitals taken on scene. You say that the Plan should process the bills.The Plan denied your request. The Plan says these services are not a covered benefit.The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on September 12, 2019. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided.Therefore, we decided that the Plan does not have to pay forthe ambulance services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 4, 2019.You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollees EOC.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 to the enrollee by an out-of-network provider on September 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on August 22, 2019 by an out of network (OON) provider.You asked the Plan to pay fordermatology 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 for these services. The plan says that 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 fordermatology services provided on August 22, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Prolia (J0897).You asked the Plan to pre-approveProlia. You say that the requested medication is necessary.The Plan denied your request. The Plan says that medical necessityhas not been established. Therefore, coverage criteria has 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 Prolia. Our reviewer says that the medication is medically necessary. Our physician reviewer found the provided medical records do support that the Prolia is medically reasonable and necessary for the enrollee. The provided medical records also support that the Prolia is safe and effective for the enrollee. There is Medicare-approved compendia support for use of Prolia for osteopenia.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Prolia have been met.Therefore, we decided that the Plan has to pre-approveProlia (J0897).
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for rehab therapy provided on July 2, 2019 to August 8, 2019 by an out of network (OON) provider.You asked the Plan to pay for rehab therapy. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says there are in-network providers available for these services. The Plan says that no prior authorization was obtained for these services.Medicare rules say that plans canrequire 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 forrehab therapy provided on July 2, 2019 to August 8, 2019 by an out of network (OON) provider
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Fentanyl 25mcg/hr patch (J3490).
You asked the Plan to pre-approve Fentanyl 25mcg/hr patch. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee has a medical only policy which does not include Part D prescription coverage, therefore the criteria for self-administered drug coverage has not been met.
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 Fentanyl 25mcg/hr patch (J3490).
Benefits for Fentanyl 25mcg/hr patch 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 physician's services for injections provided on February 6, 2019.You asked the Plan to pay for the physician's services for injections.The Plan denied your request. The Plan says the Plan requires utilization of network providers when possible and available, and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.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 did not pre-approve the servicesat 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 physician's services for injections provided on February 6, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the domiciliary or rest home visits for the evaluation and management of a new patient (99326, 99336) provided by an out of network (OON) provider from October 7, 2019 to November 15, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment of the services provided. The Plan denied your request. The Plan says services rendered by nonparticipating providers require prior authorization. The Plan did not authorize any services for the facility or the treating physician. The services rendered are not considered urgent or emergent in nature.
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 provider nor the facility in this case are network providers 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 domiciliary or rest home visits for the evaluation and management of a new patient (99326, 99336) provided October 7, 2019 to November 15, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a replacement Medtronic (MiniMed) continuous glucose monitor (CGM).
You asked the Plan to pre-approve a non-therapeutic CGM. You say that your current transmitter is faulty so your pump is unable to work. The Plan denied your request. The Plan says a Medtronic CGM is not a therapeutic CGM and therefore not covered by Medicare or the Plan.
The Plan must follow Medicare rules. Medicare rules say that only therapeutic CGMs are covered when they are medically reasonable and necessary and replace a blood glucose monitor. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a non-therapeutic CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a replacement Medtronic (MiniMed) continuous glucose monitor (CGM).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered to enrollee on March 22, 2019.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 claim was not billed correctly.The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code.We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11.Therefore, we decided that the Plan does not have to pay for the drug testing rendered to enrollee on March 22, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Repatha SureClick for the enrollee.You asked the Plan to pre-approvethis drug. You say that the enrollee's cholesterol levels are under control on Repatha.The Plan denied your request. ThePlan says that this medication is not covered under Part B.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-approveRepatha SureClick for the enrollee.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights