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

We decided that the Plan does not have to reduce the copayment forthe biopsy provided on November 5, 2019.You asked the Plan to reduce the copayment forthe biopsy. You say that you were under the impression that your copayment would be $35. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 copayment for surgical services at an in-network outpatient hospital facility. You have been asked to pay a $325 copayment for the biopsy. The biopsy falls within the "Outpatient surgery, including service 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 reduce the copayment forthe biopsy provided on November 5, 2019.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the laboratory services rendered to the enrollee on August 8, 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 that the services were not rendered.
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 states that the services were not rendered; however, the records show that the enrollee received the services at issue on the date of service at issue. The Plan has not provided any documentation to support that these services are not covered. Therefore, we decided that the Plan has to pay for the laboratory services rendered to the enrollee on August 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the outpatient surgery services you received on October 2, 2019.You asked the Plan to waive the cost share for the services provided. The Plan denied your request. The Plan says the cost share was applied correctly based on your plan 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). Your contract with the Plan clearly says that you must pay a 4% coinsurance for outpatient surgery. The records show that 4% of the allowed amount for the services provided was $1028.08. However, you have only been asked to pay $890.30, which allowed you to reach your out-of-pocket amount for the calendar year. The services fall within the outpatient surgery 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 cost share for the outpatient surgery services you received on October 2, 2019
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 September 18, 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 physician order/lab requisition or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. 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. 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 September 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 14, 2019.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 Healthcare Common Procedure Coding System (HCPCS) G0482 remains not supported.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code.In this case, the definition of HCPCS code G0482 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 15-21 drug class(es), including metabolite(s) if performed."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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our physician reviewer found no provider records have been submitted for review. Therefore, there is no documentation of provider concern for drug abuse/misuse. There is no evidence that a UDS was reviewed prior to ordering the UDT. The UDT order is not dated. Therefore, the documentation does not support that the provided, broad-sweeping, confirmatory UDT was medically necessary, reasonable or properly ordered.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 Plandoes not haveto pay fordrug testing services provided to the enrollee on May 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.You asked the Plan to pre-approve foot orthotics. You say that the requested orthotics are medically necessary because you have pain while walking.The Plan denied your request. The Plan says this item is not a covered benefit.Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.  Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition.Therefore, we decided that the Plan does not have to pre-approvefoot orthotics.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vraylar for the enrollee.
You asked the Plan to pre-approve this drug. You say that this medication has been extremely effective in stabilizing the member's depression and mania. The Plan denied your request. The Plan says that this is not covered under the member's 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 Vraylar 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 hyperbaric oxygen (HBO) therapy (99183) provided on August 14, 2019.
You asked the Plan to pay for HBO therapy. You say that this was medically necessary. The Plan denied your request. The Plan says the enrollee has skin ulcers.
The Plan follows Medicare rules. Medicare rules say that HBO therapy is not covered for the treatment of cutaneous, decubitus, and stasis ulcers or chronic peripheral vascular insufficiency. 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 HBO therapy. Our reviewer says that the criteria for coverage of HBO therapy have not been met. Our physician reviewer found the records show that the enrollee has painful skin ulcers of the extremities, torso, pannus, and penis and calciphylaxis. This description best is described by the non-covered "cutaneous, decubitus, and stasis ulcers" condition category as well as the non-covered "chronic peripheral arterial insufficiency" category. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of HBO therapy have not been met. Therefore, we decided that the Plan does not have to pay for hyperbaric oxygen (HBO) therapy (99183) provided on August 14, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a tier exception for Perforomist for the enrollee. You asked the Plan to pre-approve a tier exception. The Plan denied your request. The Plan says that tier exceptions only apply to Part D drugs
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Perforomist for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on April 19, 2019.You asked the Plan to waive the coinsurance for the office visit. You say that you were told several times you were covered. The Plan denied your request. The Plan says the claim has been adjusted and you have been charged the correct cost sharing amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% of the Medicare-allowed amount for an out-of-network primary care provider visit for Medicare-covered services. You have been asked to pay a total of $145.66 which is 50% of the allowed amount for the office visit. The total allowed amount is $291.31. ($291.31 x 50% = $145.66). The office visit falls within the of 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 coinsurance for the office visit provided on April 19, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Cyclophosphamide, Doxorubicin, Vincristine,
Prednisone, Rituximab, Palonosetron, Dexamethasone and Pegfilgrastim drug regimen for the enrollee.
You asked the Plan to pre-approve the regimen. You say that this is medically necessary. The Plan denied your
request. The Plan says Original Medicare is responsible for the coverage of routine costs associated with
clinical trials.
The Plan must follow Medicare rules. The rules say that Original Medicare pays for the routine costs of
qualifying clinical trials. Enrollees in a Medicare plan receive the same coverage for qualifying clinical trials as
people enrolled in Original Medicare. The Plan must cover only the difference between the cost-sharing in
Original Medicare and the plan cost-sharing for the same services.
In this case, you asked the Plan to pre-approve the regimen as part of a clinical trial. The Plan does not cover
routine costs associated with qualifying clinical trials. Therefore, we decided that the Plan does not have to preapprove
a Cyclophosphamide, Doxorubicin, Vincristine, Prednisone, Rituximab, Palonosetron, Dexamethasone
and Pegfilgrastim drug regimen for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided by out of network (OON) provider on October 21, 2019 and November 6, 2019.
You asked the Plan to pay for these services. You say that you are requesting reconsideration of the Plan's denial as the patient does not have a choice of the medical professionals they are seen by while in the facility. The Plan denied your request. The Plan says the services were provided 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 has network providers available who can provide the services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided by the out of network (OON) provider on October 21, 2019 and November 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve FreeStyle Freedom Lite test strips.
You asked the Plan to pre-approve the non-preferred brand of test strips. You say that the enrollee wants to
continue to use the non-preferred brand. The Plan denied your request. The Plan says there is no medical
reason documented that the enrollee is unable to use the Plan preferred meters.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We looked at the file and Medicare rules. There is no physician documentation that the non-preferred brand is
necessary to avoid an adverse medical outcome. Based on this information, we decided that Medicare rules for
coverage of the non-preferred brand of test strips have not been met. Therefore, we decided that the Plan does
not have to pre-approve FreeStyle Freedom Lite test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an implant /abutment supported removable mandibular denture for edentulous arch (D6111).
You asked the Plan to pre-approve the implant /abutment supported removable mandibular denture. You say that standard dental appliances will not work due to the extra-ordinary amount of saliva produced. You also say that this service is necessary to combat the saliva problem. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve an implant /abutment supported removable mandibular denture for edentulous arch (D6111).
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the ER visit provided on October 25, 2019.
You asked the Plan to pay for the ER visit. You say that the enrollee was not enrolled in hospice on the date of service. You say that the claim should be reprocessed for payment. The Plan denied your request. The Plan says Original Medicare is responsible for payment.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated. The enrollee ended Medicare Hospice benefits on October 22, 2019. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for the ER visit provided on October 25, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a short-latency somatosensory evoked potential study (CPT
95927) provided to the enrollee on June 7, 2019.
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 Current Procedural Terminology (CPT) code 95927 remains 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 95927 is "short-latency somatosensory evoked potential
study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the
trunk or head."
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 services. Our reviewer says that the
services at issue in this case were not supported by the medical records. Our physician reviewer found while
Erb's Point may be anatomically located near the head/neck, neurologically, Erb's Point is the coalescence of
upper extremity nerves. Monitoring Erb's Point does provide information about nerves in the head or trunk, but
rather about the upper extremity. The billing of CPT 95927 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 of the services have not been met. Therefore, we decided that the Plan does not
have to pay for a short-latency somatosensory evoked potential study (CPT 95927) provided to the enrollee on
June 7, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
You asked the Plan to pre-approve these services. You say that you need SNF care as soon as possible. The Plan denied your request. The Plan says the admission is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is 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 these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that you have developed right leg cellulitis. You have stable vital signs and an ultrasound of the leg was negative for a blood clot. You are not currently receiving any skilled therapy. You have no skilled nursing or skilled therapy needs. You do not need skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary services on an inpatient basis at the SNF level of care. 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 a skilled nursing facility (SNF) admission.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continued home health skilled nursing services.
You asked the Plan to pre-approve the continued home health skilled nursing services. You say that the enrollee cannot administer the medications and need the daily skilled nursing services. The Plan denied your request. The Plan says the enrollee does not qualify for daily skilled nursing visits. The Plan also says that the enrollee has been receiving Personal Care Attendant (PCA) services, and once a week the nurse has seen that the PCA can assist with the enrollee's medication and insulin administration.
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 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 continued skilled nursing services. Our reviewer says that the service is not medically necessary. Our physician reviewer found the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services which are medically necessary for the enrollee. Our reviewer found that the enrollee's insulin usage is not new and noted as long term. The enrollee verbalized understanding of diabetes education. Our physician reviewer also found that the enrollee has a PCA that can assist with insulin management. 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 continued skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pre-approve the continued home health skilled nursing services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Vascepa.You asked the Plan to pre-approve Vascepa. You say that you are almost out of medication.The Plan denied your request. The Plan says the requested drug isn't covered under your medical 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 Vascepa.Benefits for Vascepa may be available under Medicare Part D.Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.