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

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided on August 14, 2019.
You asked the Plan to waive the copayment for an injection. You say that all you had was an injection. You say that you expected to pay a $45 copayment. You say that you think this copayment is way too high. 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 $395 copayment for outpatient surgery. You have been asked to pay a $395 copayment for an injection. The injection that was provided is considered an outpatient surgery; therefore, the correct copayment has been applied. An injection falls 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 copayment for an outpatient surgery provided on August 14, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a fecal occult blood test (FOBT) provided on September 10, 2019.
You asked the Plan to pay for FOBT test. You say that your doctor made the decision to carry out this testing again because of your symptoms. The Plan denied your request. The Plan says the denial of payment for this service is correct, because a FOBT test was provided to you on June 5, 2019 and therefore 12 months had not passed before this test was performed.
The Plan must follow Medicare rules. Medicare rules say that fecal occult blood testing is covered once every 12 months. We looked at the file and Medicare rules. A fecal occult blood test (FOBT) was provided to you on June 5, 2019, therefore 12 months had not passed before this test was performed. Based on this information, we decided that Medicare rules for coverage of FOBT test have not been met. Therefore, we decided that the Plan does not have to pay for a fecal occult blood test (FOBT) provided on September 10, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided by the provider on September 4, 2019.
You asked the Plan to pay for lab test. You say that you are appealing with documentation supporting the code billed. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted did not include a valid physician order, lab requisition, or medical records to support the billed code.
The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of lab test have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided by the provider on September 4, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee on June 17, 2019.
You asked the Plan to pay for the diabetic supplies. The Plan denied your request. The Plan says that valid proof of delivery was not submitted.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. The tracking ticket does not include the items supplied and the delivery ticket does not include a tracking number to confirm it was delivered. Therefore, we decided that the Plan does not have to pay for the diabetic supplies provided to the enrollee on June 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided to the enrollee on July 2, 2019,
by an out-of-network provider.
You asked the Plan to pay for the medical services. You say that the services are medically necessary. The Plan
denied your request. The Plan says the member has no out of network benefits and the non-urgent services are
not authorized because the provider is a non-network provider with the member's health plan,
and another non-network provider with the member's health plan referred the member for
services. The Plan states the member self-directed and the member's network primary care physician (PCP) did
not refer for services. The Plan states they require utilization of network providers when possible and available,
and requires authorization for certain services. The Plan states there is no medical necessity for an out-ofnetwork
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 the medical services provided to the enrollee on
July 2, 2019, by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient eye exam (92004) and the eye refraction (92015) provided by an out of network provider on December 8, 2018.
You asked the Plan to pay for these services. You say that you attended this facility to obtain a replacement for your broken glasses. You also say that the facility did their job and should get paid on the basis of respect and spirit. The Plan denied your request. The Plan says the services were provided by an out of network provider without prior authorization, and were not urgent in nature.
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 new patient eye exam (92004) and the eye refraction (92015) provided by the out of network provider on December 8, 2018.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on September 3, 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 the records do not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that a physician order must be present for labs to be covered. The documentation submitted did not include a physician order/lab requisition or medical records stating exactly tests were to be performed. 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 drug testing services provided to the enrollee on September 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an upper airway stimulation device (64568, 0466T).
You asked the Plan to pre-approve an upper airway stimulation device. You say that the requested item is medically necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. Medicare rules say that CPT codes 0466T, 0467T, 0468T and 64568 are not reasonable and necessary under 1862(a)(1)(A) of the Social Security Act for patients with an obstructive sleep apnea (OSA) diagnosis. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an upper airway stimulation device have not been met. Therefore, we decided that the Plan does not have to pre-approve an upper airway stimulation device (64568, 0466T).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the humerus fracture treatment provided from May 23, 2019 through May 24, 2019.
You asked the Plan to waive the coinsurance for the humerus fracture treatment. You say that you were admitted as an inpatient. You say that you should only be responsible for $275 per day. The Plan denied your request. The Plan says the coinsurance 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 20% coinsurance for each covered surgery or observation room service in an outpatient hospital. You have been asked to pay $2,040.31, which is 20% of the allowed amount for the humerus fracture treatment. The allowed amount is $10,201.54 (20% x $10,201.54 = $2,040.31). The humerus fracture treatment falls within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" benefit category. The records show that this was an outpatient procedure.
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 humerus fracture treatment provided from May 23, 2019 through May 24, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for 2 units of low osmolar contrast material (Q9966) provided on August 12, 2019.
You asked the Plan to pay for the low osmolar contrast material. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted medical records do not indicate that 2ml of low osmolar contrast material, 200-299 mg/ml iodine concentration was administered.
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 Q9966 is low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml. We asked our coder 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 low osmolar contrast material. Our reviewer says that 2 units of Q9966 is not supported by the medical record. Our reviewer found the record states that a total of 1 ml of omnipaque was injected. This supports 1 unit of Q9966. 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 low osmolar contrast material have not been met. Therefore, we decided that the Plan does not have to pay for 2 units of low osmolar contrast material (Q9966) provided on August 12, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 31, 2019 by an out of network provider.
You asked the Plan to pay for laboratory testing. You say that this claim was denied in error, and the codes billed are in fact valid for this date of service. The Plan denied your request. The Plan says the denial of payment for these services is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan.
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 medical services provided on July 31, 2019 by the out of network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the complete series of intraoral x-rays and comprehensive oral evaluation provided on December 10, 2018.
You asked the Plan to pay more for the prophylaxis, intraoral x-rays, and comprehensive oral evaluation. You say that you do not understand how you could have received the maximum amount of coverage allowed for these services. The Plan denied your request. The Plan says you had already received the maximum amount of coverage allowed for these services.
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 Plan offers a $150 allowance every year for non-Medicare covered preventive dental services. The contract also says you are responsible for any amount above the dental coverage limit. The record shows that you met the annual allowance benefit on December 10, 2018 and your annual allowance benefit was then exhausted. Therefore, we decided that the Plan does not have to pay more for the complete series of intraoral x-rays and comprehensive oral evaluation provided on December 10, 2018.
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 necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but you do not require this on an intensive rehabilitation facility therapy program level 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aranesp.
You asked the Plan to pre-approve the Aranesp. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the medical necessity of a step therapy exception.
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 the Aranesp. Our reviewer says that you have not tried and failed a trial of Retacrit. Our physician reviewer found Aranesp is not indicated for the treatment of your condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Aranesp have not been met. Therefore, we decided that the Plan does not have to pre-approve Aranesp.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an annual wellness visit (G0439), an electrocardiogram, (an EKG) (93000), and an annual depression screening (G0444) provided on September 17, 2019.
You asked the Plan to waive the copayment for an annual wellness visit, an EKG, and an annual depression screening. You say that you requested to have a preventative checkup and according to the description of benefits, preventative care should not have a payment. The Plan denied your request. The Plan says there is no coinsurance, copayment, or deductible for the annual wellness visit. However, if you are also treated or monitored for an existing medical condition during the visit when you receive the preventive service, a $10 copayment will apply for the care received for the existing medical condition. The Plan also says that outpatient diagnostic tests have a $20 per day for covered tests. Other outpatient diagnostic tests include but are not limited to, sleep studies, EKGs, stress tests, vascular studies, and breathing capacity tests.
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 for physician services and a $20 copayment for outpatient diagnostic tests. You have been asked to pay a $10 copayment for physician services and a $20 copayment for an EKG, and an annual depression screening. These services fall within the physician services and outpatient diagnostic tests benefit category ($10 + $20 = $30). 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 annual wellness visit (G0439), an electrocardiogram, (an EKG) (93000), and an annual depression screening (G0444) provided on September 17, 2019.
Appeal type: Lab
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 July 8, 2019.
You asked the Plan to pay for the services. 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 July 8, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on March 5, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says the 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 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 physician's services provided on March 5, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prostatic arterial embolization for the enrollee.
You asked the Plan to pre-approve the procedure. You say that this is medically necessary. The Plan denied your request. The Plan says medical studies haven't proven that this procedure is helpful for treatment of the enrollee's health problem.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the procedure. Our reviewer says that the requested procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found prostatic arterial embolization (PAE) is an experimental technique to treat symptomatic BPH. Very limited international studies have demonstrated possible short-term safety and efficacy. Comparative studies to standard treatments such as TURP have not demonstrated significant advantages with regard to safety and functional outcomes. 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 procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve prostatic arterial embolization for the enrollee.