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

We decided that the Plan does not have to pre-approve chiropractic services.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your
request. The Plan says the medical records do not show that the back bones are not aligned properly.
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.
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 services Our reviewer says that the
requested services are not medically reasonable or necessary. Our physician reviewer found the record
indicates that the enrollee has lumbosacral back pain. The provided record does not indicate that the enrollee
has subluxation as demonstrated by x-ray or physical examination. The elements of the coverage criteria are
not satisfied.
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 services have not been met. Therefore, we decided that the Plan does not
have to pre-approve chiropractic services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an eye refraction provided on June 9, 2021.

You asked the Plan to pay for an eye refraction. The Plan denied your request. The Plan says refractions are only covered if they are routine and performed by a routine provider.

Medicare does not pay for procedures performed in the course of any eye exam to determine the refractive state of the eyes. Refractive procedures are not covered even when done in connection with otherwise covered diagnosis or treatment of illness or injury.

We looked at the file and the Medicare rules. The file shows that you received an eye exam for a Medicare-covered eye condition and not a routine eye exam. Medicare does not cover refractive procedures even when done in connection with otherwise covered diagnosis or treatment of illness or injury Therefore, we decided that the Plan does not have to pay for an eye refraction provided on June 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 24, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the office visit. You say that the enrollee needed to be seen after an emergency room visit to rule out an infection. 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visit provided on December 24, 2020, by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services (CPT code(s): 97110, 97140, G0283) provided to the enrollee on April 30, 2021, by an out-of-network provider

You asked the Plan to pay for the physical therapy services. You say that the claim should be paid, and the services were referred by a network provider. The Plan denied your request. The Plan says this provider is out-of-network, the services were not referred by a network provider, and the services were not urgent or emergent, nor were they approved in advance.

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 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 the physical therapy services (CPT code(s): 97110, 97140, G0283) provided to the enrollee on April 30, 2021, by an out-of-network provider
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bronchial thermoplasty treatments.

You asked the Plan to pre-approve the bronchial thermoplasty. You say that this would be beneficial for the enrollee's condition. The Plan denied your request. The Plan says this is still considered an experimental treatment.

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 bronchial thermoplasty. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee is a 64-year-old woman with a diagnosis of severe persistent asthma with chronic obstructive pulmonary disease (COPD) overlap with fixed obstruction, as well as obesity and obstructive sleep apnea. The enrollee had a recent case of COVID-19 pneumonia. 

The documentation is insufficient to demonstrate that bronchial thermoplasty is medically reasonable and necessary for the enrollee in this case. The evidence is inconclusive regarding the efficacy of bronchial thermoplasty in this setting.

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 bronchial thermoplasty have not been met. Therefore, we decided that the Plan does not have to pre-approve bronchial thermoplasty treatments.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.
You asked the Plan to pre-approve the continuous glucose monitor. You say that the continuous glucose monitor is 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 therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day or use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit and laboratory test provided on July 8, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for office visit and lab test. You say that you are appealing this denial. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and authorization was not 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 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 an office visit and laboratory test provided on July 8, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for magnetic resonance imaging, spinal canal and contents
(72148) provided June 3, 2021
You asked the Plan to pay for the diagnostic services. You say that please review the attached reports and
reconsider the claim for payment. The Plan denied your request. The Plan says the explanation of benefits from
the primary carrier has not been received.
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for
services until the claim for those services has gone to the primary insurer. However, plans are still required to
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a
bill for reimbursement to the primary insurer.
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has another
insurance as the primary payor. As the secondary insurer, the Plan cannot be held responsible for the diagnostic
services until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan
does not have to pay for magnetic resonance imaging, spinal canal and contents (72148) provided June 3, 2021
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (99233) provided on December 18, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the principal
diagnosis was inappropriately coded.
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 submitted documentation does not contain a claim form showing the billed
diagnosis codes. Without supporting documentation that shows that billed diagnosis codes, the Plan's denial
cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (99233) provided on
December 18, 2020.
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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the scanning computerized ophthalmic diagnostic imaging services you received on June 3, 2021, and June 4, 2021, and the medical eye exam you had on June 4, 2021.
You asked the Plan to waive the copayments for the scanning computerized ophthalmic diagnostic imaging services and the medical eye exam. You say that you thought there would only be one office visit copayment for these services. The Plan denied your request. The Plan says you were charged these copayments correctly. The Plan says that for the scanning computerized ophthalmic diagnostic imaging services, since the allowed amount for these services ($39.64 each) is less than your copayment obligation, you are responsible for the full allowed amount for these services.
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 $75 copayment for non-radiologic diagnostic procedures and tests and a $50 copayment for medical eye exams. Records show that you had a medical eye exam on June 3, 2021, and you were charged a $50 copayment for that visit. You are not appealing that copayment. You have been asked to pay a $75 copayment for each of the scanning computerized ophthalmic diagnostic imaging services and a $50 for the medical eye exam you had on June 4, 2021. The scanning computerized ophthalmic diagnostic imaging services fall within the non-radiologic diagnostic procedures and tests benefit category. Diagnostic testing is separate from the office visit, so separate cost sharing applies. In addition, you pay the medical eye exam copayment each time you have such a visit. You had two visits, so two copayments apply. 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 copayments for the scanning computerized ophthalmic diagnostic imaging services you received on June 3, 2021, and June 4, 2021, and the medical eye exam you had on June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided by an out-of-network provider on May 7, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not approved in advance.
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 had network providers available who could have provided 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 services provided by an out-of-network provider on May 7, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 23,
2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request.
The Plan says the services are not urgent, emergent, or approved in advance.
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 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 laboratory services provided to the enrollee on
March 23, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the fundus photography, interpretation and report (92250)
provided June 14, 2021.
You asked the Plan to pay for the diagnostic vision services. You say that this eye exam was needed because of
your acute diabetes. You have not had one in a few years. The Plan denied your request. The Plan says this
service is not covered under the Plan benefits.
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in
this case. The Plan does not have coverage for fundus photography.
We looked at the file and the Plan's rules. This service is not covered under the Plan benefits. Based on this
information, we decided that the Plan's rules for coverage of the diagnostic vision services have not been met.
Therefore, we decided that the Plan does not have to pay for the fundus photography, interpretation and report
(92250) provided June 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 4, 2021.
You asked the Plan to waive the copayment for a colonoscopy. You say that you had the colonoscopy due to a false positive Cologuard test and were not sick before or after. 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 a $400 copayment for outpatient surgery, including services provided at hospital outpatient facilities. The medical records show that you received a colonoscopy on May 4, 2021, at an outpatient hospital facility, due to a positive Cologuard test. Therefore, the colonoscopy is considered diagnostic and you are responsible to pay the $400 copayment.
You have been asked to pay a $400 copayment for a colonoscopy. A colonoscopy falls within the outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a colonoscopy provided on May 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the protein laboratory coded 84165 provided on January 27, 2021.

You asked the Plan to pay for the protein laboratory. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, the protein laboratory, 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 for the protein laboratory coded 84165 provided on January 27, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ondansetron for the enrollee.

You asked the Plan to pre-approve this drug. You say that the enrollee needs this to treat nausea and vomiting due to gastroparesis and gastroenteritis. The Plan denied your request. The Plan says that this 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-approve Ondansetron for the enrollee.

Benefits for this drug 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 the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on November 13, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue.
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care, per day (99308) rendered by the out-of-network (OON) provider on November 13, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Xarelto 20 mg tablet.
You asked the Plan to pre-approve Xarelto tablet. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have 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 drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Xarelto 20 mg tablet.
Benefits for Xarelto tablet 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: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound study of extremity veins (93971) provided on February 5, 2021, by an out-of-network provider.
You asked the Plan to pay for an ultrasound study of extremity veins. You say that the services at issue were rendered to the enrollee in good faith. The Plan denied your request. The Plan says rules for out-of-network care have not been met.
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 had network providers available who could have provided 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 an ultrasound study of extremity veins (93971) provided on February 5, 2021, by an out-of-network provider.