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

We decided that the Plan does not have to waive the coinsurance for the Avastin injection provided on January 16, 2020.You asked the Plan to waive the coinsurance for the injection. You say that this should be covered.The Plan denied your request. The Plan says that you must pay a 20% co-insurance for Medicare Part B-covered drugs.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 Prescription Drugs. You have been asked to pay a 20% coinsurance for the injection. The injection 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 coinsurance for the Avastin injection provided on January 16, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on September 11, 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 procedure code 95937 is 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 95937 is neuromuscular junction testing (repetitive
stimulation, paired stimuli), each nerve, any 1 method.
We find that CPT code 95937 is not supported in the medical record. Specifically, the documentation supports
that Train of Four testing was performed and this is not the appropriate code for these services. 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 testing services rendered on September 11, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Hizentra injection (J1559).
You asked the Plan to pre-approve the Hizentra injection. You say that the enrollee has coming variable immune deficiency. You also say that the enrollee has low responses to vaccine titers and significant recurrent infections. The Plan denied your request. The Plan says the documentation does not show that the enrollee has a primary immune deficiency disease.
The Plan must follow Medicare rules. Medicare rules say that Hizentra is not a covered benefit under Medicare Part B. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of Hizentra have not been met. Specifically, this drug is listed on the Self-Administered Drug Exclusion list, and is not a covered benefit. Therefore, we decided that the Plan does not have to pre-approve the Hizentra injection (J1559).
Benefits for the Hizentra injection 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided to the enrollee on February 23, 2018.You asked the Plan to pay for the lab services. You say that the enrollee's active policy was kept from you.The Plan denied your request. The Plan says the time limit for filing has expired.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010 must be filed no later than one calendar year after the date of service.The record shows that a claim for the lab services was not filed until November 8, 2019. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the lab services provided to the enrollee on February 23, 2018.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 4, 2019.You asked the Plan to pay forthe orthosis. You say that the claim should be paid.The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items orderedand for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified.Therefore, we decided that the Plan does not have topay fora knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on December 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 8, 2019.
You asked the Plan to pay for the orthoses. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use. The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for a knee orthosis with suspension sleeve (L1833, L2397) provided to the enrollee on November 8, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transport provided on November 20, 2019.
You asked the Plan to waive the copayment for the ambulance transport. You say that your primary care physician requested the service. You say that you should not be billed. 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 $50 for Medicare-covered ambulance services per day. You have been asked to pay a $50 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 November 20, 2019.
Appeal type: Imaging
Decision: Favorable

We decided that the Planhasto pre-approve a PET/CT scan of the skull base to mid-thigh for the enrollee.You asked the Plan to pre-approve the scan. You say that this is medically necessary.The Plan denied your request. The Plan says that there is no indication of worsening symptoms suspicious for new metastatic disease, and there is currently no treatment being received.The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rulesto determine if the Plan was correct in denying the request to pre-approve the scan. Our reviewer says that the requested scan is medically reasonable and necessary. Our physician reviewer found ordinarily conventional imaging such as CT would be adequate to monitor therapy or presence of tumor recurrence. The problem here is the enrollee has an intramedullary rod in her humerus which will produce marked artifact making CT of limited value. In addition, one would expect a bone scan to remain positive with the history of rod placement and pathologic fracture for a long time. Thus, the scan which would be most sensitive to evaluate for tumor recurrence would be a PET scan which will search for areas of increasing metabolic activity which in turn would be suspicious for tumor.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 scan have been met.Therefore, we decided that the Planhas to pre-approvea PET/CT scan of the skull base to mid-thigh for the enrollee.If the Plandoes 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 toreview. The Plan has to show us the mistake and/orsend 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reduce the copayment for the cystourethroscopy provided on November 18, 2019.
You asked the Plan to reduce the copayment for the cystourethroscopy. You say that the allowed amount is lower than your husband's $400 copayment. You say you would like to pay the lower amount. 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 $400 copayment for outpatient hospital facility. You have been asked to pay a $400 copayment for the cystourethroscopy. The cystourethroscopy falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The record shows the allowed amount is $652.54. ($652.54 - $400 copayment = $252.41. This amount is the Plan's share).
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 for the cystourethroscopy provided on November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an injection provided on November 14, 2019. You asked the Plan to waive the deductible for an injection. You say that you do not know why this is being applied to your deductible. The Plan denied your request. The Plan says the correct deductible amount has been applied. The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $183 deductible for Medicare Part B prescription drugs. The item or service you asked the Plan to waive the deductible for falls within the benefit category Medicare Part B prescription drugs. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $183 deductible for Medicare Part B prescription drugs. The total amount you are being asked to pay is $116.08. This cost sharing is a contractual obligation that had not been met at the time an injection was received on November 14, 2019. Therefore, we decided that the Plan does not have to waive the deductible for an injection provided on November 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for services provided by a licensed massage therapist on May 31, 2019 to October 23, 2019.You asked the Plan to pay for the services provided. You say that in the past, you have been reimbursed for the code at issue.The Plan denied your request. The Plan says the providers are not medical professionals.The Plan must follow Medicare rules. Medicare does not cover the services ofa massage therapist.Therefore, we decided that the Plan does not have to pay forservices provided by a licensed massage therapist on May 31, 2019 to October 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reduce the cost share for the vision services provided on November
15, 2019.
You asked the Plan to reduce the cost share for the vision services. You say that you were never told the doctor
was out-of-network. 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. Your
contract with the Plan says that there is a $370 deductible that applies towards out-of-network vision services
and 20% of the cost, after the deductible, for out-of-network exams to diagnose and treat diseases and
conditions of the eye.
The vision services you asked the Plan to reduce the cost share for falls within the "Vison care" benefit
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $370
deductible that applies towards vision services and 20% of the cost, after the deductible, for out-of-network
exams to diagnose and treat diseases and conditions of the eye. The record shows the provider is out-ofnetwork.
See chart below.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay formedical services (CPT 77002 and HCPCS Q9966) provided to the enrollee on October 4, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the records do not support the service billed.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 the denied codes is:HCPCS Q9966:Low osmolar contrast material, 200-299 mg/ml iodine concentration, per mlCPT 77002:Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure). We asked our coding 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 denied codes at issue in this case were not supported by the medical records. Our coding reviewer found the medical records do not include documentation of 10 units of Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml (HCPCS Q9966) being administered on October 4, 2019, therefore, this service cannot be verified. CPT 77002 is an add-on code. None of CPT 77002's covered primary codes were submitted for reimbursement consideration on the same date of service, by the same physician. Therefore, it is not eligible for separate reimbursement.We looked at this coder'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 formedical services (CPT 77002 and HCPCS Q9966) provided to the enrollee on October 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an ultrasound provided on November 21, 2019.
You asked the Plan to waive the copayment for an ultrasound. You say that you feel that the ultrasound should not be considered a radiological diagnostic service. 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 radiological diagnostic services such as ultrasounds. You have been asked to pay a $75 copayment for an ultrasound. An ultrasound falls within the outpatient diagnostic test 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 an ultrasound provided on November 21, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the Part B injections provided on November 14, 2019 and December 18, 2019.
You asked the Plan to waive the coinsurance for the Part B injections. You say that you are dissatisfied with the amount you have to pay. 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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a total of $397.23 for the Part B injections. The Part B injections falls within the "Medicare Part B prescription drugs" benefit category. See chart below.
Date of Service
Service
Allowed Amount
Coinsurance
Member Liability
November 14, 2019
Afibercept injection
$1,904.94
20%
$380.99
December 18, 2019
Bevacizumab injection
$81.18
20%
$16.24
Total
$397.23
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 Part B injections provided on November 14, 2019 and December 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient lab work provided on November 29, 2019. You asked the Plan to waive the copayment for lab work. You say that you already reached your maximum out-of-pocket amount. The Plan denied your request. The Plan says the correct copayment has been 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 $35 copayment for outpatient diagnostic tests/in-network/labs. You have been asked to pay $30 which is less than your copayment amount of $35 due to reaching your maximum out-of-pocket expense amount. Lab work falls within the outpatient diagnostic tests/in-network/labs 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 outpatient lab work provided on November 29, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for a new patient visit provided on December 10, 2019.
You asked the Plan to pay for new patient visit. You say that you saw this provider for the first time at this visit. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because you were seen by this provider within 3 years prior to this visit.
The Plan must follow Medicare rules. Medicare rules say that a "new patient" is a patient who has not received any professional services from the physician or physician group practice (same physician specialty) within the previous 3 years. We looked at the file and Medicare rules. Although you received professional service from the facility within 3 years prior to this visit, your previous visit was attended to by a physician of a different specialty. Therefore, the use of a "new patient" visit code is appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of new patient visit have been met. Therefore, we decided that the Plan has to pay for a new patient visit provided on December 10, 2019.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound provided on August 2, 2019 by an out of network (OON) provider.
You asked the Plan to pay for an ultrasound. You say that these services were necessary. You say that you were unaware that the member had an HMO plan. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there is no network deficiency for these services and alternate network providers were found.
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 an ultrasound provided on August 2, 2019 by an out of network (OON) provider
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance fordiagnostic procedures and tests provided form November 13, 2019 to November 15, 2019.You asked the Plan to waive the coinsurance for diagnostic procedures and tests. You say that this is the highest bill you ever received and 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 20% coinsurance.You received diagnostic procedures and tests from November13, 2019 to November 15, 2019. The total allowed amount is $18,266.61 and 20% of that is $3,653.32.   You have been asked to pay the total coinsurance amount of $3,653.32 for diagnostic procedures and tests. Diagnostic procedures and tests 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 coinsurance for diagnostic procedures and tests provided form November 13, 2019 to November 15, 2019.