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

We decided that the Plan does not have to waive the coinsurance for the Part B drugs you received from September 25, 2019, to October 14, 2019. You asked the Plan to waive the coinsurance. You say that this should be covered 100%. The Plan denied your request. The Plan says you are responsible for the cost share. 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 20% coinsurance for Medicare Part B covered drugs. Review of the file shows that you were provided Part B drugs from September 25, 2019, to October 14, 2019. You have been asked to pay a 20% coinsurance for the drugs. The drugs fall within the Medicare Part B covered 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. Please note that the plan is reprocessing the claim to remove the coinsurance responsibility for the administration of the drugs, as this service is not subject to cost sharing. Therefore, we decided that the Plan does not have to waive the coinsurance for the Part B drugs you received from September 25, 2019, to October 14, 2019.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance transport provided to the enrollee on March 13, 2019. You asked the Plan to pay for the ambulance services. You say that the transport was before hospice enrollment. The Plan denied your request. The Plan says 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. 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 ambulance transport provided to the enrollee on March 13, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan denied your request. The Plan says the services are not medically necessary. The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above. 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 IRF care. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee presented to the emergency department (ED) on March 5, 2020 for frequent falls. The workup in the ED revealed a normal head computed tomography (CT) scan, right hip, and pelvic x-rays that were negative with no obvious seizures. He has no complex needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require an intensive therapy program in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 20 skilled nursing visits and 275 home infusion therapy visits to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve 20 skilled nursing visits and 275 home infusion therapy visits. You say that you would like the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are neither emergent nor urgent to seek out-of-network care. The Plan states there are equally qualified in-network providers available that can provide the care and services being requested. The Plan says they confirmed with the providerl that they can provide all the care and services being requested.
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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 20 skilled nursing visits and 275 home infusion therapy visits to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-ofnetwork
provider on December 12, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services
rendered by non-participating providers in non-participating facilities require prior authorization as outlined in
the enrollee's EOC.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan has network providers
available who can provide the 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 medical services provided to the enrollee by an out-of-network provider
on December 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for radiation treatment provided on November 15, 2019 and November 18, 2019.
You asked the Plan to waive the copayment for radiation treatment. You say that the cost is a lot. You say that you want help with the copayment. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $60 copayment for each Medicare-covered, in-network, radiation (radium and isotope) therapy service. You have been asked to pay a $60 copayment for each radiation treatment. The total amount you owe is $120 ($60/treatment x 2 treatments = $120). Radiation treatment falls within the "Outpatient diagnostic tests and therapeutic services and supplies" 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 radiation treatment provided on November 15, 2019 and November 18, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 14, 2019 through October 21, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration because per Medicare, CPT code S9328 is valid. The Plan denied your request. The Plan says CPT code S9328 has a status code of I which is not valid for Medicare purposes.
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 code S9328 is not supported in the record. Specifically, per the Physician Fee Schedule, CPT code S9328 has a status indicator of I. This means that CPT code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (S9328) provided on October 14, 2019 through October 21, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the chronic care management services (99490) provided by out of network (OON) provider on November 30, 2019.
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were provided by an out of network provider at a non-participating facility, 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 chronic care management services (99490) provided by the out of network (OON) provider on November 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy services (HCPCS S9328) provided to the enrollee from December 1, 2019 to December 8, 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 this is an invalid procedure code. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that HCPCS code S9328 is not supported in the medical record. Specifically, this code has a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 home infusion therapy services (HCPCS S9328) provided to the enrollee from December 1, 2019 to December 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on October 25, 2019. You asked the Plan to pay for the services. The Plan denied your request. The Plan says non-emergent services rendered by non-participating providers in non-participating facilities require prior authorization as outlined in the enrollee's EOC. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the 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 medical services provided to the enrollee by an out-of-network provider on October 25, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee by an out-of-network provider on September 10, 2019. You asked the Plan to pay for the services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were 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 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 medical services provided to the enrollee by an out-of-network provider on September 10, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lift system for use with outdoor stairs. You asked the Plan to pre-approve an outdoor lift system. You say that the enrollee cannot leave his home for appointments or any other reason without the assistance of this lift. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because this item is not covered by Medicare. The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pre-approve a lift system for use with outdoor stairs.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a colonoscopy provided by the Surgery Center on November 12, 2019.
You asked the Plan to waive the copayment for a colonoscopy. You say that you should not owe a copayment for colonoscopy screenings. 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 $75 copayment for each ambulatory surgical center visit. The medical records show that you had polyps removed during a colonoscopy on November 12, 2019. Therefore, the colonoscopy is considered diagnostic, not preventative, and you are responsible to pay the $75 copayment. You have been asked to pay a $75 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 by the Surgery Center on November 12, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the epidural injection provided on August 12, 2019 and disc surgery provided from October 14, 2019 through October 15, 2019. You asked the Plan to waive the copayment for the epidural injection and disc surgery. You say that the injection caused damage and the surgery should have been inpatient. You say that the copayment should be lowered. The Plan denied your request. The Plan says the copayments applied correctly. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $200 copayment per date of service for outpatient surgery at an ambulatory surgical center and a $350 copayment per date of service for outpatient surgery at an outpatient hospital facility. You have been asked to pay a $200 copayment for the epidural injection and a $350 copayment for disc surgery. The total amount you owe is $550 ($200 + $350 = $550). The epidural injection and disc surgery fall 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 the epidural injection provided on August 12, 2019 and disc surgery provided from October 14, 2019 through October 15, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

You asked the Plan to pay for the services. You say that this should be covered. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services (CPT 99203) you received on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a routine eye refraction provided on September 16, 2019. You asked the Plan to pay for eye refraction. You say that you had a lack of confidence in the doctor you previously saw, and felt you had to do something else to have your vision checked. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this service is not covered by the Plan except when provided by a Vision Care provider. 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 these services when provided by a Vision Care provider. We looked at the file and the Plan's rules. This eye refraction was not provided by a Vision Care provider. Based on this information, we decided that the Plan's rules for coverage of eye refraction have not been met. Therefore, we decided that the Plan does not have to pay fora routine eye refraction provided on September 16, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on April 10, 2019. You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says the denied billed procedures require the skill and training for a provider who specializes in laboratory/pathology. 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 pay for the services. Our reviewer says that the services at issue in this case are not medically reasonable or necessary. Our physician reviewer found in the case of this enrollee, the completed lab testing performed on 4/10/2019 was not combined with a complete history and physical with documentation of the indication and clinical applicability of the performed testing in order to support it's completion. Therefore, without sufficient justification made, the requested lab tests will be considered not medically necessary at this time. 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 lab services provided to the enrollee on April 10, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the SNF services.
You asked the Plan to pre-approve the SNF services. You say that the enrollee needs SNF services before he can go home; this is important for him to maintain his quality of life. The Plan denied your request. The Plan says the enrollee was enrolled in a Federal Medicare-certified hospice program, which was revoked on March 8, 2020. The Plan coverage does not start again until the first day of the following month.
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 March 8, 2020. Original Medicare continues to pay for services furnished after the revocation or expiration of the enrollee's hospice election until the first day of the month after the hospice election has been revoked or terminated. The SNF services being requested are before the end of the month of the hospice revocation date. Therefore, we decided that the Plan does not have to pre-approve the SNF services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Atezolizumab for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the use of Atezolizumab is not FDA approved for this type of cancer and there is lack of support for its use in the Medicare references.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found this drug is not FDA approved for large cell neuroendocrine cancer of colon. It is also not supported in any of the compendia or the literature for the enrollee's diagnosis. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Atezolizumab for the enrollee.