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

We decided that the Plan does not have to waive the copayment for a CT scan provided on October 22, 2019.
You asked the Plan to waive the copayment for a CT scan. You say that you disagree with the charges. 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 $250 copayment for advanced imaging services provided at an outpatient hospital facility. You received a CT scan at an outpatient hospital facility on October 22, 2019. Therefore, you are responsible to pay the $250 copayment. You have been asked to pay a $250 copayment for a CT scan. A CT scan falls within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a CT scan provided on October 22, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammogram provided on October 2, 2019.
You asked the Plan to waive the copayment for the mammogram. You say that your previous mammogram costed less. You say that you should be charged less since the cost is the same. 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 $0 copayment for diagnostic procedures and tests at a physician's office and a $125 copayment for diagnostic procedures and tests at any other location. You have been asked to pay $109.42, which is less than the standard $125 for the diagnostic mammogram. The mammogram 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 the diagnostic mammogram provided on October 2, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from October 23, 2018 to December 21, 2018.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you cannot afford the copayments. You say if you had been informed in advance of the copayment amount, you would not have had so many visits. 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 $75 copayment for each out-of-network Medicare-covered physical therapy and speech-language therapy visit. For the December 12, 2018, December 17, 2018, December 19, 2018, and December 21, 2018 dates of service, you have been asked to pay the allowed amount of the claim because these amounts are less than the $75 copayment for out-of-network physical therapy visit.
You have been asked to pay a $75 copayment for the physical therapy visits. ($75 x 19 visits = $1,425). You have also been asked to pay a $32.07 copayment for the December 12, 2018, December 17, 2018, December 19, 2018, and December 21, 2018 dates of service. ($32.07 x 4 = $128.28). ($1,425 + $128.28 = $1,553.28).
That means 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 physical therapy visits provided from October 23, 2018 to December 21, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home visit services provided on July 5, 2019 by an out of
network provider.
You asked the Plan to pay for the home visit services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
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 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 home visit services provided on July 5, 2019
by an out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for testing of autonomic (sympathetic) nervous system function (95924) provided on June 24, 2019 by an out of network provider.
You asked the Plan to pay for testing of autonomic (sympathetic) nervous system function. You say that you do not feel responsible for these charges. The Plan denied your request. The Plan says the non-urgent services were not authorized because the provider is a non-network provider with the member's health plan, which takes precedence over the claim system denial. The member's network primary care physician (PCP) did not refer for services. The health plan requires utilization of network providers when possible and available and requires authorization for certain services. No medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been documented.
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 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 testing of autonomic (sympathetic) nervous system function (95924) provided on June 24, 2019 by an out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Stiolto Respimat Inhalation Spray.
You asked the Plan to pre-approve the Stiolto Respimat Inhalation Spray. You say that this drug is medically necessary for the member. The Plan denied your request. The Plan says the member has a medical only Plan, therefore, benefits are limited to Medicare Part B prescription drugs.
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 Stiolto Respimat Inhalation Spray.
Benefits for the Stiolto Respimat Inhalation Spray 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: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp for the enrollee.
You asked the Plan to pre-approve Aranesp. You say that Retacrit is only offered to those on dialysis. The Plan denied your request. The Plan says the enrollee has not had an inadequate response to Retacrit therapy for at least two consecutive months with appropriate dose adjustment.
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Aranesp. Our physician reviewer found that the enrollee has anemia and chronic kidney disease. The Plan requires a trial of drug Retacrit first before they will approve the requested drug. The provided medical records do not indicate that the enrollee has tried and failed the required drug. The provided medical records do not indicate that the Plan's required drug would likely be less effective, or likely have adverse effects for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 8, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were informed your wife couldn't transport you due to stability issues. You say that the copayment for hospital to hospital transport should be waived. 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 $200 copayment per one-way trip for each Medicare-covered ambulance service. You have been asked to pay a $200 copayment for the ambulance transport. The ambulance transport falls within the "Ambulance services" benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ambulance transport provided on September 8, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the physical therapy visits provided from August 19, 2019 to August 21, 2019.
You asked the Plan to waive the copayments for the physical therapy visits. You say that you should not be responsible for the bills because you did not actually have any physical therapy. 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 $40 copayment per day for in-network Medicare-covered physical therapy services. You have been asked to pay a $40 copayment for each of the physical therapy visits. The physical therapy visits fall within the "Outpatient rehabilitation services" benefit category. The record shows the therapeutic exercises were provided for joint disorders.
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 physical therapy visits provided from August 19, 2019 to August 21, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee is a fall risk and needs physician care. 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 was admitted to the hospital on December 31, 2019 after an unwitnessed fall. She was found to have a chronic closed displaced fracture of the neck with delayed healing. She is independent with bed mobility and is walking 500 feet with assistance and a walker. She has no complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. She may benefit from additional 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing rendered to the enrollee on September 20, 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 there is no valid physician order.
The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician. We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 pay for the definitive drug testing rendered to the enrollee on September 20, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on September 25, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that you should not owe anything for laboratory services. 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 $10 copayment lab services provided in an outpatient hospital facility. You received laboratory services provided at an outpatient hospital facility on September 25, 2019. Therefore, you are responsible to pay the $10 copayment. You have been asked to pay a $10 copayment for laboratory services. Laboratory services fall within the outpatient hospital services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for laboratory services provided on September 25, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 12, 2019 by an out-of-
network 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 genetic testing from both in- and out-of-network providers requires 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 has network providers
available who can provide 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 laboratory services provided on July 12, 2019
by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology gene expression profiling services provided on August 30, 2019.
You asked the Plan to pay for the oncology gene expression profiling. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not billed correctly.
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 81518 is Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy. We find that CPT code 81518 is not supported in the medical record. Specifically, this code was billed with a secondary only diagnosis code as the primary procedure code. A secondary only diagnosis cannot be used as the primary, first-listed, or principal diagnosis for any procedure or service. Based on this information, we decided that Medicare rules for coverage of the oncology gene expression profiling have not been met. Therefore, we decided that the Plan does not have to pay for the oncology gene expression profiling services provided on August 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not haveto pre-approve Xeljanz XR (J8499).You asked the Plan to pre-approve The Xeljanz XR. You say that the member has been taking this medication since 2014 and it would be a risk for the member to not resume the medication. The Plan denied your request. The Plan says the member has a medical only policy with the Plan, therefore, drug coverage is limited to Medicare Part B covered drugs.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 Xeljanz XR (J8499). Benefits for The Xeljanz XR may be available under Medicare Part D.Contactthe 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 paring or cutting of benign hyperkeratotic lesion services
provided on October 14, 2019.
You asked the Plan to pay for the paring or cutting of benign hyperkeratotic lesion services. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services
received are not a covered benefit.
The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is
for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or
feet or have fungal nails.
Records do not show that any of these conditions are present. The services you are asking the Plan to pay for
are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the
paring or cutting of benign hyperkeratotic lesion services have not been met. Therefore, we decided that the
Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion services provided on October 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the injections provided on August 28,
2019.
You asked the Plan to waive the copayments for the injections. You say that you were informed there was no
copayment for a follow up visit. You say that you should not be billed. 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 $15
copayment per day for drugs that are professionally administered and a $15 copayment for each specialist visit
for Medicare-covered services. Covered services include medically-necessary medical care or surgery services
furnished in a physician's office.
You have been asked to pay a total of $18.18 for the injections.

   
Service: Triamcinolone Acetonide Injection
Allowed Amount: $3.18 
Standard Copayment: $15 
Member Liability: $3.18

Service: Spine Injection 
Allowed Amount: $241.94 
Standard Copayment: $15 
Member Liability: $15

TOTAL Member Liability: $18.18

The triamcinolone acetonide injection falls within the "Medicare Part B prescription drugs" benefit category.
The spine injection falls within the ""Physician/Practitioner services, including doctor's office visits" benefit
category. The records show that the office visit was for the injections. 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 injections provided on August 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on July 10, 2019 by an out-of-network 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-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 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. 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 laboratory services provided on July 10, 2019 by an out-of-network provider.