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

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.You asked the Plan to pre-approve continued SNF services. The Plan denied your request. The Plan says 100 SNF days have been reached.The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and ends when the enrollee has gone60 days in a row without inpatient hospital or SNF care. The file shows that the enrollee received 100 days of SNF care during the benefit period from August 24, 2019 to January 6, 2020. The Plan has covered 100 days of SNF care. Although the enrollee may still need skilled care, the Plan is not required to pay for more than 100 days of SNF coverage during this benefit period. The enrollee will be eligible for a new benefit period when the enrollee has not been receiving care in a hospital or skilled care in a SNF forat least 60 days in row.Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from August 21, 2019 to August 28, 2019.
You asked the Plan to pay for the home infusion therapy services. You say that you would like the plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that that home infusion services and supplies may be covered as a supplemental benefit. Home infusion therapy supplies are not covered by Original Medicare. The plan does not include a mandatory supplemental benefit for home infusion therapy services or supplies. We looked at the file, Medicare rules, and the plan's rules. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy services have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services (S9328) provided from August 21, 2019 to August 28, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tramadol Hcl Tab 50mg.
You asked the Plan to pre-approve Tramadol Hcl Tab 50mg. You say that the medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Tramadol Hcl Tab 50mg.
Benefits for Tramadol Hcl Tab 50mg 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 an office visit, non-spinal chiropractic manipulation, physical therapy, and X-Ray examinations provided by the physician from April 3, 2019 to April 22, 2019. 
 
You asked the Plan to pay for chiropractic services. You say that you were told that the Plan reimbursed these services, and these charges have created a hardship for you. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor. 
 
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 the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit, non-spinal chiropractic manipulation, physical therapy, and X-Ray examinations provided by the physician from April 3, 2019 to April 22, 2019.  
 
Please note that this decision is only regarding dates of service April 3, 2019 to April 22, 2019. Please contact the Plan regarding appeals for any other items or services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring system.
You asked the Plan to pre-approve a continuous glucose monitor. You say that your glucose drops in between meals and your doctor advised that you need a continuous glucose meter. The Plan denied your request. The Plan says you are not insulin treated so you do not meet the Medicare coverage criteria for a CGM.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are covered only 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 continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle Libre Continuous Glucose Monitoring system.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a high efficiency particulate air (HEPA) air purifier.
You asked the Plan to pre-approve the air purifier. You say that you need the air in your house to be purified for health issues. The Plan denied your request. The Plan says this item is not covered as it does not meet the criteria for durable medical equipment.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a high efficiency particulate air (HEPA) air purifier.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the OneTouch Ultra Blue Test Strip.
You asked the Plan to pre-approve the strip. You say that this is medically necessary. The Plan denied your request. The Plan says it has other preferred meters and test strips.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the strip. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating that the enrollee requires the specific OneTouch Ultra Blue Test Strip. The Plan has other preferred meters and test strips. The requested OneTouch Ultra Blue Test Strip is not medically necessary and reasonable. 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 strip have not been met. Therefore, we decided that the Plan does not have to pre-approve the OneTouch Ultra Blue Test Strip for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for Bedside drainage bag (A4357) and urinary suspensory w/o leg b (A4359) provided on December 8, 2018.
You asked the Plan to pay for the urological Supplies. You say that you are submitting the Plan Medicare Advantage policy guidelines which supports the services billed with medical records. Please review for payment. The Plan denied your request. The Plan says HCPCS codes A4357 and A4359 were not billed with an appropriate modifier.
The Plan must follow Medicare rules. Medicare rules say that claims lines billed without a KX, GA, GY or GZ modifier will be rejected as missing information. Based on this information, we decided that Medicare rules for coverage of the urological Supplies have not been met. Therefore, we decided that the Plan does not have to pay for Bedside drainage bag (A4357) and urinary suspensory w/o leg b (A4359) provided on December 8, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a critical care and evaluation (99292, 99291), and an electroencephalogram (EEG) (95819)
You asked the Plan to pay for a critical care and evaluation, and an EEG. You say that services were medically necessary on dates of service August 11, 2019 to August 23, 2019. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized by 7:00 p.m. on August 10, 2019 and all subsequent care was post stabilization care, not approved in compliance with the health plan's authorization procedures because the enrollee refused to repatriate. The Plan paid for all emergent care up 12:43 a.m. on August 11, 2019 when a notice of non-compliance (NONC) for refusal to transfer was issued to the enrollee 
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision care provided on October 8, 2019 by an out of network (OON) provider.
You asked the Plan to pay for vision care. You say that you were told by the Plan's customer service rep that said that they would pay you as an in-network since the member as incorrectly given information about being in-network. The Plan denied your request. The Plan says there are in-network providers available. The Plan says that 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 for vision care provided on October 8, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the 4Kscore testing rendered to the enrollee on September 23, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that 4Kscore testing is not reasonable and necessary and is not covered by Medicare. The test at issue is the 4Kscore test. This test is not covered by Medicare for any indication. Therefore, we decided that the Plan does not have to pay for the 4Kscore testing rendered to the enrollee on September 23, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care from September 16, 2019 through September 18, 2019 provided by an in-network provider.
You asked the Plan to waive the copayment for inpatient hospital care. You say that you should be charged the outpatient hospital copayment amount. The Plan denied your request. The Plan says the claim was processed accordingly with your 2019 EOC 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). The information provided shows you presented to the emergency room for chest pain. You had to be admitted to the hospital for respiratory support and cardiac monitoring in an intensive care setting. You were charged a copayment amount of $720 for two days of inpatient hospitalization per your Benefit Plan responsibility, which states a $360 copayment is applied to each inpatient day in the hospital. Based on the services rendered (surgical, lab work, imaging, medications, diagnostic tests, etc.), a total observation copayment amount would be well over the $720 inpatient copayment. Your estimated outpatient/observation financial responsibility would have been over $900 which would not include copayments for professional services from the physicians that took care of you. The health plan contract says that enrollees must pay a $360 copayment per day, days 1 to 5 for in-network inpatient hospital care. 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 inpatient hospital care from September 16, 2019 through September 18, 2019 provided by an in-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on September 5, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that yes, your provider is out-of-network but, you say that your doctor has served you and the Plan a great service. The Plan denied your request. The Plan 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 for physician services provided on September 5, 2019 by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Orencia injection.
You asked the Plan to pre-approve the Orencia injection. You say that the requested drug is medically necessary for treatment of the enrollee's rheumatoid arthritis. The Plan denied your request. The Plan says the requested medication falls under Part D coverage, but the enrollee has no Part D pharmacy benefit managed by the plan.
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 an Orencia injection.
Benefits for the Orencia injection 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Plavix Tab 75mg.
You asked the Plan to pre-approve Plavix Tab 75mg. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage.
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 Plavix Tab 75mg.
Benefits for Plavix Tab 75mg 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on August 15, 2019.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the documentation submitted did not include a valid physician order/lab requisition.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. The records provided do not contain a valid physician order or lab requisition stating exactly which testing was to be performed. Additionally, the records provided do not contain documentation of the ordering physician's intent that the testing be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on August 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tasigna 150mg capsule
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this is a Medicare plan that only has Part B coverage.
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 Tasigna 150mg capsule
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on October 9, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that the urgent care staff informed you to take an ambulance to the hospital. You say that you thought you were going to a hospital. 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 for all other members of the Southern California Region, enrollees must pay a $200 copayment per one-way trip. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. The records show that you were transported by ambulance to the hospital. 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 ambulance transport provided on October 9, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 15, 2019 by out of
network provider.
You asked the Plan to pay for office visit. You say that your practice will assist any individuals based on
medical necessity. 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 physician 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 August 15, 2019
by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for Retacrit for the enrollee.
You asked the Plan to provide coverage for Retacrit. You say that this treatment is medically necessary. The Plan denied your request. The Plan says this is not a medical necessity denial but an administrative one. Medicare says certain drugs for dialysis patients are covered under the 'bundled' payment to the dialysis facility. This applies even if the treated condition is not related to end stage renal disease or the dialysis, and even if a prescription is written. The Plan says that under the Plan MAPD plan, neither the Part B nor D can cover a drug meeting criterion for coverage by the bundled payment for dialysis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT codes. In this case, the requested drug cannot be separately covered outside of the bundled relationship with the payments for dialysis treatment. Medicare rules for coverage of Retacrit have not been met. Therefore, we decided that the Plan does not have to provide coverage for Retacrit for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided to the enrollee on November 11, 2019. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the documentation did not include lab results for 15-21 confirmatory drug classes. Code G0481 is more appropriate. 
 
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 G0482 is definitive drug testing of 15-21 classes. 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 testing services. Our physician reviewer found that while twenty-two drugs were tested for, these drugs can be grouped into fewer than fifteen classes. Therefore, the billing of G0482 is not supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided to the enrollee on November 11, 2019.