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

We decided that the Plan does not have to pay for the services rendered on July 31, 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 codes 95907 and 95885 are 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 95907 is nerve conduction studies; 1-2 studies. The definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure). We find that CPT code is not supported in the medical record. Specifically, the technical report does not include documentation of 1-2 nerve conduction studies to support code 95907. The technical report does not include documentation of limited needle electromyography being performed to support code 95885. 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 services rendered to on July 31, 2019.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services provided from September 19, 2019 to September 23, 2019.
You asked the Plan to pay for the emergency department services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the enrollee was enrolled in hospice for these dates of service.
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 the emergency department services provided from September 19, 2019 to September 23, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for laboratory testing and an X-Ray examination provided on November 29, 2019.
You asked the Plan to waive the copayments for lab tests and X-Ray. You say that these services were completed in a clinic setting. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct.
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 $40 copayment for lab tests and $100 copayment for X-Ray received from an in-network outpatient hospital facility. You have been asked to pay $40 copayment for lab tests, however you have only been asked to pay $60 for the X-Ray exam which is less than the applicable $100 copayment. Therefore, your total copayment obligation is $100. You have been asked to pay $40 copayment for lab tests and less than $100 copayment for X-Ray. Lab tests and X-Ray fall 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 copayments for laboratory testing and an X-Ray examination provided on November 29, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the nuclear stress test provided on December 10, 2019.
You asked the Plan to waive the copayment for the nuclear stress test. You say that you received an approval letter that said the nuclear stress test would be fully covered. The Plan denied your request. The Plan says the deductible amount was removed and you are only responsible for the copayment.
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 for each advanced imaging service (e.g., MRI, CT and PET scan, nuclear medicine, and stress tests). You have been asked to pay a $200 copayment for the nuclear stress test. The nuclear stress test 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 nuclear stress test provided on December 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the specialist office visit provided on November 13, 2019.
You asked the Plan to waive the copayment for the specialist office visit. You say that this visit was for a dressing change and a follow-up from your surgery on November 5, 2019. You say there should not be a copayment. 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 $45 copayment for services obtained from a specialist, or under certain circumstances, treatment by a nurse practitioner or physician's assistant or other non-physician health care professionals in a specialist's office. You have been asked to pay a $45 copayment for the specialist office visit. The specialist office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. Please note, there is no provision in the contract which indicates a copayment would be waived if performed as a follow-up to a surgical 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 copayment for the specialist office visit provided on November 13, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Opdivo.

You asked the Plan to pre-approve Opdivo. You say that the requested Opdivo is medically necessary. The Plan denied your request. The Plan says the requested Opdivo is not medically necessary.

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 Opdivo. Our reviewer says that the requested Opdivo is not medically necessary. Our physician reviewer found the enrollee is diagnosed with adrenal cancer. She then developed liver metastases, confirmed by biopsy on January 6, 2020. Nivolumab for adrenal cancer is not FDA approved. Use is not supported by major drug compendium or the medical literature. In addition, the enrollee has already progressed on pembrolizumab and another checkpoint inhibitor is unlikely to be effective. The service is not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Opdivo have not been met. Therefore, we decided that the Plan does not have to pre-approve Opdivo.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a Nuclear Bone Scan (78320) provided December 12, 2019 by the provider.
You asked the Plan to waive the copayment for the bone scan. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $250 copayment for diagnostic imaging. You have been asked to pay a $250 copayment for the bone scan. The bone scan falls within the diagnostic imaging 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 Nuclear Bone Scan (78320) provided December 12, 2019 by the provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. You asked the Plan to pre-approve SNF 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 Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for observation care provided on December 17, 2019.
You asked the Plan to waive the copayment for the observation care. You say that the copayment should be waived. The Plan denied your request. The Plan says the correct copayment was 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 $250 copayment for Observation Level Care. You have been asked to pay a $250 copayment for the observation care. 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 observation care provided on December 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on July 2, 2019.
You asked the Plan to pay for the hospital outpatient clinic visit. The Plan denied your request. The Plan says out-of-network providers are available only when your medical group does not have the appropriate expertise in their network.
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 a hospital outpatient clinic visit provided on July 2, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the level of service requested is considered necessary for those who must require daily skilled nursing services or to two hours of skilled therapy daily that can only be provided in the skilled nursing facility.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the admission. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. You do not require skilled nursing of therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria on an inpatient basis in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for office visits provided on August 30, 2018 and September 18, 2019. You asked the Plan to waive the copayments for primary care visits. You say that you feel you should not be responsible for these copayments because the visits were only annual wellness visits. The Plan denied your request. The Plan says the copayment amounts you are being charged are correct. 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 $5 copayment for each in-network primary care visit in 2018 or 2019. These visits included non-routine diagnoses that go beyond the Annual Wellness Visit, so office visits with copayments were billed in addition to your Annual Wellness Visits. Your total copayment obligation is therefore $10. You have been asked to pay $5 copayment for each primary care visit. Primary care visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayments for office visits provided on August 30, 2018 and September 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to payforthe anesthesia services rendered to the enrollee on April 4, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says minor pain procedures do not require anesthesia outside of local anesthesia.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We looked at the file and Medicare rules. The file shows that the provider submitted a claim for procedure code 01936 (anesthesia for percutaneous image guided procedures on the spine and spinal cord; therapeutic). There is no documentation to support that the anesthesia services were necessary for the procedure. 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 forthe anesthesia services rendered to the enrollee on April 4, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to payforthe application of hot or cold packs (97010) provided on February 12, 2019.You asked the Plan to pay forthe application of hot or cold packs. You say that this should be covered because your doctor ordered it and it has been helpful.The Plan denied your request. The Plan says this service is not covered by Medicare or the Plan.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 forthe application of hot or cold packs (97010) provided on February 12, 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 November 18, 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 November 18, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on March 13, 2019 by an out of network (OON) provider.
You asked the Plan to pay for office services. You say that you were not advised that this provider was no longer in-network with the Plan, and you have been a patient of this doctor for many years. 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 prior authorization was not obtained.
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 March 13, 2019 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the POV, group 1 heavy duty, patient weight capacity 301 to 450 pounds (K0801).
You asked the Plan to pre-approve the POV. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the POV have not been met. A Heavy Duty POV is covered for a beneficiary weighing 285 - 450 pounds. You weigh 230 pounds. Therefore, we decided that the Plan does not have to pre-approve the POV, group 1 heavy duty, patient weight capacity 301 to 450 pounds (K0801).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forassembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided to the enrollee on November 7, 2019.You asked the Plan to pay forthe services. You say that the claim should be paid.The Plan denied your request. The Plan says the Medicare rules have not been met.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. The enrollee received the services in the facility during inpatient hospitalization, and payment for this service would be included in the part-A DRG payment to the facility. Payment for this service is the responsibility of the facility to any vendor.Therefore, we decided that the Plan does not have to pay forassembly and operation of pump with oxygenator or heat exchanger (with or without ECG and/or pressure monitoring); each hour (CPT Code 99190) provided to the enrollee on November 7,2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyewear provided on November 13, 2019.You asked the Plan to pay an additional amount for the eyewear. The Plan denied your request. The Plan says the claim process correctly.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. We looked at the file and the Plan's rules. The file shows that the $375.00 allowance plus 20% is the benefit allowance deducted by the provider at the point of service. You are responsible for the balance after the benefit has been paid. Therefore, we decided that the Plan does not have to pay an additional amount for eyewear provided on November 13, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home delivered meals.You asked the Plan to pre-approve home delivered meals. You say that you just got out of the hospital and were receiving meals.The Plan denied your request. The Plan says the service is not medically necessary.The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home delivered meals have not been met. The service is not medically necessary under CMS (Centers for Medicare and Medicaid Services) criteria if a prescription is not received from your provider. The Plan states after several attempts, they did not receive a provider prescription or discharge order showing medical necessity.Therefore, we decided that the Plan does not have to pre-approve home delivered meals.