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

We decided that the Plan does not have to waive the coinsurance for part B drugs provided on January 13, 2021.

You asked the Plan to waive the coinsurance for part B drugs. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance you are being charged is correct.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% coinsurance for Medicare-covered Part B chemotherapy drugs and other Part B drugs.

The allowed amount of the claim is $8,215.20, resulting in a coinsurance obligation of $1,643.04 for part B drugs ($8,215.20 x 20%). Part B drugs fall within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for part B drugs provided on January 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88305) provided on January 13, 2021 by an out of network (OON) provider.

You asked the Plan to pay for OON laboratory services. You say that this should be covered. The Plan denied your request. The Plan says this was not authorized.

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 (88305) provided on January 13, 2021 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for treatment with Prolia provided on January 12, 2021.

You asked the Plan to waive the co-payment for Prolia. You say that there is nothing in the book that says anything about 20% coinsurance for Part B medication. The Plan denied your request. The Plan says the correct co-payment was applied.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% coinsurance for Medicare Part B covered chemotherapy drugs and other Part B covered drugs.

You have been asked to pay $85.53, or 20% of the Medicare-allowed amount of $427.65, for Prolia. Prolia falls within the "Medicare Part B prescription drugs" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the co payment for treatment with Prolia provided on January 12, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on October 23, 2020 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that these services were provided in good faith that reimbursement would be issued. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 psychotherapy services provided on October 23, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for inpatient services provided from September 15, 2020, to September 18, 2020.
You asked the Plan to adjust the copayment for the inpatient services. You say that the enrollee was only inpatient for two days. The Plan denied your request. The Plan says the enrollee was charged this cost share 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). The contract with the Plan clearly says that the enrollee must pay a $325 copayment per day for days 1-5 for Inpatient Hospital Care. The enrollee was asked to pay a $325 copayment per day for days 1-3, for the inpatient services. The inpatient services fall within the Inpatient Hospital Care benefit category. The record shows the enrollee was inpatient for three days. This means that the enrollee was asked to pay the correct amount based on their contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay when enrolling in the Plan. Therefore, we decided that the Plan does not have to adjust the copayment for inpatient services provided from September 15, 2020, to September 18, 2020.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pre-approve inpatient psychiatric hospital services.

You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the services are necessary. The Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.

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 inpatient psychiatric hospital services. Our reviewer says that the services are medically necessary. Our physician reviewer found based upon review of the records provided, the admission of this enrollee does meet criteria for acute inpatient mental health treatment as although she was not shown to be a danger to herself or others, this enrollee was floridly psychotic with auditory hallucinations.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric hospital services have been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric hospital services.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the member can remain in the current acute care location until such time no further acute level care is needed.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services provided on December 17, 2020 by an out of network (OON) provider.
You asked the Plan to pay for psychotherapy services. You say that these services were provided in good faith. You say that you would like this claim reprocessed and paid. The Plan denied your request. The Plan says prior authorization was not obtained by the member's primary care physician.
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 psychotherapy services provided on December 17, 2020 by an out of network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional PT.

You asked the Plan to pre-approve additional PT. The Plan denied your request. The Plan says additional PT is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 

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 additional PT. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that in this case, the enrollee has previously been treated with outpatient therapies including aquatic physical therapy and should be independent with a home exercise program. The additional therapy services are not an appropriate duration and frequency for the enrollee's condition and therefore are not 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 the additional PT. have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on July 7, 2020 by a nonparticipating
provider.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were rendered by a non-participating 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 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 office visit provided on July 7, 2020 by a non-participating provider.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for office visit services (CPT 99214) provided to the enrollee on January 7, 2021.
You asked the Plan to pay for the services. You say that POS 12 (home) is an allowable location for all temporary telephonic codes. The Plan denied your request. The Plan says that POS 12 (home) is not an appropriate location for these services.
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 99214 is "office or other outpatient visit for the evaluation and management of a new patient." We looked at the file, and Medicare rules and decided that CPT 99214 is supported. The file shows that the office visit was telephonic, therefore, a place of service of "Home" would be appropriate in this case. Additionally, part of the plan's denial is that the submitted documentation does not support the visits as being performed by the billed provider on the date of service at issue in this case. There is nothing in the case file to suggest this. The plan has not substantiated their denial. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for office visit services (CPT 99214) provided to the enrollee on January 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Protonix (pantoprazole) to be administered intravenously (IV) by a home health nurse.

You asked the Plan to pre-approve the IV Protonix. You say that the enrollee requires the use of this medication. The Plan denied your request. The Plan says this service is being requested with an invalid code.

The Plan must follow Medicare rules. The rules say that Medicare does not pay for drugs/biologicals under the home health benefit. Medicare Part B does not cover drugs that are usually self-administered by the enrollees who take them. 

In this case, the drug is being requested through a home health agency. The home health benefit does not provide coverage for drugs. In addition, although this is requested for IV administration, this medication is usually administered orally by most patients. As it is usually self-administered, it cannot be covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Protonix (pantoprazole) to be administered intravenously (IV) by a home health nurse.

Benefits for the IV Protonix 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the four crowns (D2740 x4) provided on December 3, 2020.

You asked the Plan to pay for the crowns. You say that you would like these services to be covered The Plan denied your request. The Plan says these services are not covered under your dental plan.

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 four crowns (D2740 x4) provided on December 3, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Whole Exome Sequence analysis (81415).

You asked the Plan to pre-approve the Whole Exome Sequence analysis. You say that the member's symptoms are difficult to manage, unresponsive to standard treatments and some genetic forms of these conditions are amendable to specific treatments. The Plan denied your request. The Plan says this testing is not a Medicare covered benefit.

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 Whole Exome Sequence analysis. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found at the present time the applicable LCD does not demonstrate that coverage is readily provided for the use of whole exome sequencing in dystonia syndromes. Furthermore, the utility of said testing the segment of the population with adult onset dystonia syndromes is even more limited. Given these limitations the proposed testing would not be readily expected to lead to any significant changes or improvement in management of the member's condition.

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 Whole Exome Sequence analysis have not been met. Therefore, we decided that the Plan does not have to pre-approve the Whole Exome Sequence analysis (81415).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Group 3 Power Mobility Device.
You asked the Plan to pre-approve the Group 3 Power Mobility Device. You say that you would like reconsideration because the requested power mobility device is medically necessary. The Plan denied your request. The Plan says the member does not have neurological condition, myopathy or congenital skeletal deformity.
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair can be covered only for enrollees who have a mobility limitation that is due to a neurological condition, myopathy or congenital skeletal deformity. 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 Group 3 Power Mobility Device. Our reviewer says that it appears the member would more appropriately be served by a group 2 power wheelchair rather than the requested group 3 chair. Our physician reviewer found records clearly document that the patient's mobility deficit is related to the amputations and not the cerebrovascular disease.
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 Group 3 Power Mobility Device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Group 3 Power Mobility Device.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a SNF stay on December 8 to December 31, 2020.

You asked the Plan to waive the copayment for a SNF stay. You say that you were informed your insurance would pay the bill at issue. The Plan denied your request. The Plan says the correct copayment was applied.

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 $160 copayment for per day per admission for days 21-100 of a SNF stay. 

You have been asked to pay a $472.79 copayment for days 21-36 of a SNF stay. A SNF stay falls within the "Skilled nursing facility (SNF) care" benefit category. This means that you have been asked to pay less than or equal to 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 SNF stay on December 8 to December 31, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an office visit provided on January 4, 2021.

You asked the Plan to waive the copayment for an office visit. You say that this was your annual wellness exam and you should not owe a copayment. 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 $15 copayment for primary care provider visits. 

The medical records show that you received services beyond an annual wellness exam on January 4, 2021. Therefore, you are responsible to pay the $15 copayment.

You have been asked to pay a $15 copayment for an office visit. An office visit falls within the physician/practitioner services, including doctor's office visits 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 an office visit provided on January 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for contact lenses (V2520 x2) received on February 11, 2021.
You asked the Plan to pay for contact lenses. You say that you thought the provider was in-network. The Plan denied your request. The Plan says the provider is not part of the vendor network for routine eyewear.
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 covers routine eyewear when the Plan's network providers are utilized. We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of contact lenses have not been met. Specifically, services were provided by an out-of-network provider. The Plan has network providers available to provide these services. 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 contact lenses (V2520 x2) received on February 11, 2021.