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

We decided that the Plan does not have to pay for physician's services provided on May 23, 2021.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for physician's services provided on May 23, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Irinotecan injections you received from June 1, 2021, to June 30, 2021.
You asked the Plan to waive the coinsurance for the Irinotecan injections. You say that you were told that your chemotherapy was covered 100%. The Plan denied your request. The Plan says you were charged this coinsurance 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 20% coinsurance for chemotherapy drugs. You have been asked to pay 20% coinsurance for the Irinotecan injections. The Irinotecan injections fall within the chemotherapy 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 for the Irinotecan injections you received from June 1, 2021, to June 30, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied
your request. The Plan says the step therapy requirement is not met.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain
Part B medications.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that
the services are not medically necessary. Our physician reviewer found the enrollee has anemia of
myelodysplastic syndrome. She has not tried and failed the Plan's required drug, at least two consecutive
months of Retacrit. The records do not support that the required drug would be contraindicated or less
effective; therefore, Aranesp is not reasonable or medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not
have to pre-approve Aranesp
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Botox.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that Botox is covered when specific criteria are met. 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee is diagnosed with myalgia and piriformis syndrome. She does not have a diagnosis for Botox is covered. The criteria for coverage are not met and the Botox is not reasonable or medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Botox.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided March 8, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 out of network physician services provided to the enrollee on March 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hearing aids. 
 
You asked the Plan to pre-approve hearing aids. You say that you need replacement hearing aids because you 
believe that your hearing aids were stolen. You say the hearing aids never fit correctly and kept falling off. The 
Plan denied your request. The Plan says you previously met your benefit limit for hearing aids on  
October 8, 2020. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for 
hearing aids only every 3 years. 
 
We looked at the file and the Plan's rules. The file shows you previously used the hearing aid benefit on 
October 8, 2020, and you are not eligible to receive the benefit at this time. Based on this information, we 
decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we decided that the 
Plan does not have to pre-approve hearing aids.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network imaging services provided to the enrollee on January 6, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 out of network imaging services provided to the enrollee on January 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve oral surgery (21031, 99153, 99152). 
 
You asked the Plan to pre-approve the oral surgery. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the requested service is not a covered benefit. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of your teeth or the structures directly supporting your teeth. The services is being requested to prepare the 
mouth for a partial denture. These are dental services that are not covered or paid for by Medicare. Therefore, 
we decided that the Plan does not have to pre-approve oral surgery (21031, 99153, 99152).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (0012M) provided February 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that non-coverage has been reaffirmed for CxBladder 
testing 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (0012M) provided February 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on 
July 22, 2021. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided 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 out of network physician services provided to the 
enrollee on July 22, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the ophthalmic ultrasound provided on April 7, 2021. 
 
You asked the Plan to pay for the ophthalmic ultrasound. You say that code 76514 was necessary to measure 
the thickness of the lens. The Plan denied your request. The Plan says the billed service is not supported. 
 
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 76514 is ophthalmic ultrasound, diagnostic; corneal 
pachymetry, unilateral or bilateral (determination of corneal thickness). 
 
We asked our coder 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 ophthalmic ultrasound. Our reviewer says that this does 
not meet the criteria for coverage. Our reviewer found that the documentation did not include the ophthalmic 
ultrasound and therefore, this service cannot be confirmed as performed.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hospice caregiver services provided from
May 19, 2019, through June 25, 2020.
You asked the Plan to reimburse you for hospice caregiver services. The Plan denied your request. The Plan says the services submitted for reimbursement are for hospice care, which should be billed to Original Medicare and not our Plan.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to reimburse you for hospice caregiver services provided from
May 19, 2019, through June 25, 2020.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the office visit and related services provided April 26, 2021.
You asked the Plan to pay for the office visit and related services. You say that you would like these claims reprocessed and approved for payment. The Plan denied your request. The Plan says that these claims have denied correctly.
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. 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 has not provided a valid argument to justify the denial of payment. Though it is true that these codes are not payable under the Outpatient Prospective Payment System (OPPS), physicians who provide services in the outpatient hospital setting are paid under the Physician Fee Schedule. The documentation available shows that the claim was filed by a physician, and not by the facility at which the services were rendered. As such, the denial rationale regarding the payment indicator in the OPPS is not applicable to this case. Therefore, we decided that the Plan has to pay for the office visit and related services provided April 26, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the myocardial perfusion imaging you had on March 11, 2020.
You asked the Plan to waive the copayment for the myocardial perfusion imaging. You say that you didn't receive a bill so you didn't know that you owed this money. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that you are only responsible for the $195 copayment, not the coinsurance originally charged for the dye used during the test.
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 $195 copayment for diagnostic and nuclear medicine radiological services. You have been asked to pay a $195 copayment for the myocardial perfusion imaging. The myocardial
perfusion imaging falls within the diagnostic and nuclear medicine radiological 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 for the myocardial perfusion imaging you had on March 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for physician services provided to the enrollee on April 19, 2021.
You asked the Plan to pay for these services. You say that these claims should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided 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 to the enrollee on April 19, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on April 12, 2021. 
 
You asked the Plan to pay for ambulance response and treatment, no transport. You say that Motor City called 
the ambulance without you asking to have the ambulance. You say that you only had your blood pressure 
checked by the paramedics and you do not feel you should be responsible for the charges. The Plan denied your 
request. The Plan says if an ambulance is called and you received care and you decide not to be transported to 
the hospital, we do not cover those services. 
 
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 April 12, 2021. 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 for ambulance response and treatment, no transport 
(A0998) provided on April 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care.
You asked the Plan to pre-approve acute inpatient hospital care. 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 inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient admission are met in this
case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis to be provided by the requested out-of-network 
provider. 
 
You asked the Plan to pre-approve dialysis to be provided by the requested out-of-network provider. The Plan 
denied your request. The Plan says we have previously approved dialysis with this provider as an exception to 
allow the enrollee time to find an in-network provider. There are other providers that we do cover that can give 
you the same care. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
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. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve dialysis to 
be provided by the requested out-of-network provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) provided on May 18, 2021.
You asked the Plan to pay for ambulance response and treatment, no transport. You say that an ambulance was called to the location where you received the Coronavirus vaccine because you had an allergic reaction to the vaccine. The Plan denied your request. The Plan says if there is no transport to the hospital, there is no coverage.
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 May 18, 2021. 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 for ambulance response and treatment, no transport (A0998) provided on May 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the $235 copayment charged for ambulance transport 
provided on May 16, 2021. 
 
You asked the Plan to waive this copayment. You say that you cannot afford this copayment. The Plan denied 
your request. The Plan says this copayment is a contractual obligation. 
 
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 $235 
copayment for ambulance transport. 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 $235 copayment charged 
for ambulance transport provided on May 16, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99225, 99217) provided March 7, 2021 
to March 8, 2021. 
 
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 99225, & 99217 are not supported in the medical record. Specifically, for evaluation 
and management services provided on the same day to the same patient by the same physician, only one 
evaluation and management service may be reported. Based on this information, we decided that Medicare 
rules for coverage of the physician services have not been met. Therefore, we decided that the Plan does not 
have to pay for physician services (99225, 99217) provided March 7, 2021 to March 8, 2021.